General Surgery Basics

For Clinicians

ROBOTIC TAPP INGUINAL HERNIA REPAIR

Disclaimer: This information is provided for quality and educational purposes only. Always rely on your personal clinical judgement as a physician when modifying any surgical technique.

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ROBOTIC TAPP INGUINAL HERNIA REPAIR

Over 800,000 Inguinal hernia repairs are performed annually in the USA. Minimally invasive or laparoscopic hernia repairs offer small incisions, decreased post-operative pain, quicker recovery and return to work. Robotic-assisted surgery adds increased precision, a 3D/Magnified view, facilitated tasks such as suturing, fewer complications including lower blood loss and decreased risk of wound infections.

Patient selection:

Almost all candidates for an open inguinal hernia repair are suitable for a robotic approach.
Robotic surgery offers a clear advantage in obese patients.
Contraindications to robotic surgery include inability to tolerate pneumoperitoneum.
Relative Contraindication: Prior intra-abdominal trauma (laparotomy) or extensive intra-abdominal surgery/prior catastrophes.
Special circumstances to consider performing an open approach may include: Complex cases such as recurrence from a prior laparoscopic/robotic approach, massive or incarcerated inguinal-scrotal hernias, prior prostate surgery or other extensive pelvic surgery or pelvic radiation. EXPERT SURGEONS may attempt robotic approach, but consider using 4th arm in these cases as time in OR is more costly than additional arm drape/instruments.
Robotic Surgery offers clear advantage in obese patients: Lower risk of infection as compared to open, and better visualization as compared to Laparoscopic TEPP approach.

Setup/Preoperative Considerations:

Foley catheter (optional) vs In and Out cath bladder to empty prior to surgery.
Patient placed in the supine position with both arms extended.
Trendelenburg position following induction of anesthesia. Consider slight flexion which helps keep arms away from patient’s face if no contraindications (ie prior extensive vertebral surgery/stenosis, etc.)
Proper face protection/padding by anesthesia.

Access:

3-arm robotic technique (no need for 4^th arm).
Optical trocar access via LUQ incision with laparoscope.
Placement of two other 8 mm robotic trocars in the upper midline, RUQ (around 8 cm apart).

All trocars are in a horizontal line, around 4 cm above umbilicus.

Technique:

Lysis of adhesions as necessary.
Identify anatomical landmarks: medial/lateral umbilical ligament, internal inguinal ring, external iliac vessels, inferior epigastric vessels, gonadal vessels/spermatic cord, arcuate line.
Preperitoneal dissection/release of peritoneal flap: a curvilinear incision is made from the median umbilical ligament to the anterior superior iliac spine, at least 6 cm above the hernia defect. Dissection of the preperitoneal space continues in the avascular plane with caution to avoid neurovascular structures.
Medial extent of dissection: To the midline of the symphysis pubis or up to 1cm beyond the midline to the contralateral side.
Lateral extent of dissection: Transection of the transverses abdominus fascia in order to stay in correct space and identify transversus abdominus muscle which should be anterolateral landmark.
Caudal extent of dissection: around 4 cm below iliopubic tract and 2 cm below Cooper’s ligament medially.
Posterior Medial dissection: Down to psoas muscle as most recurrences are from mesh folding up from medial/posterior aspect.
Dissection/Exposure of Cooper’s ligament.
Reduction of the hernia, content and sac with care not to injure the spermatic cord or vessels.
Detach hernia sac to help reduce the chance or hernia recurrence and seroma.
Reduction of cord lipomas is important, taking care to protect cord structures, and overly aggressive dissection That can cause injury to genitofemoral branch of ileoinguinal nerve. Do not need to amputate cord lipoma, leaving pedicle cephelad. Lipoma may be placed over mesh once deployed to prevent flipping of mesh anteriorly from posterior medial aspect.
Suture closure of direct hernia defect optional.
Mesh Placement into the preperitoneal space: Mesh size approximately 10x15cm. Consider 13 x 17 cm mesh that is anatomically shaped similar to Bard 3D Max, using a plain 15 x 15 cm Progrip mesh with template obliquely to obtain proper dimensions. Benefits include cost savings compared to using smaller Progrip marketed hernia mesh or Bard 3D Max, as well as being anatomically shaped. Additional cost savings is made when performing bilateral inguinal hernias by using 30 x 15 cm Progrip mesh cut in 1/2 and then cutting out mirror images using template.
Mesh type: self-fixating (eg Progrip) vs. other mesh which may require suture fixation. Consider cost in your hospital.
Closure of preperitoneal flap/peritoneum: Absorbable suture (eg barbed suture such as running 2-0 V-Lock). Any breach in peritoneum to be repaired. If usisng a barbed suture, recommend Connell suture to imbricate peritoneum over barbed edges which have been found to cause SBO. SBO risk can be reduced with traditional vicryl closure.
Consider spraying local anesthetic directly over Ileoinguinal nerve distribution in the preperitoneal space through one of the tracer port, directing flow with instrument prior to closure of flaps.
Assure hemostasis.
Undock Robot/remove trocars/release pneumoperitoneum.
Consider local anesthetic injection at trocar sites.

Postoperative Care:

Patient is discharged same day from ambulatory surgery.
Consider non-opioid analgesics.

References:

La Grange, S., Gokcal, F., Kudsi, O.Y. (2021). Robotic TAPP for Inguinal Hernia Simple to Complex. In: Gharagozloo, F., Patel, V.R., Giulianotti, P.C., Poston, R., Gruessner, R., Meyer, M. (eds) “Robotic Surgery.” Springer, Cham. https://doi.org/10.1007/978-3-030-53594-0_85

RECOMMENDATIONS ON COST SAVINGS

Supplies:	Using 2 (preferred) vs 3 Instruments	Instrument Costs
2 Instrument technique:	Mega suturecut and Fenestrated Bipolar or Force Bipolar	$630
3 Instrument technique:	Cadiere Grasper, hook cautery, mega suturecut	$780
3 Instrument technique:	Cadiere Grasper, scissors, mega suturecut	$900

TIPS AND TRICKS FOR EFFICIENCY

Consider Foley: Many of these patients have prostate issues and preop bladder emptying does not guarantee near-empty urinary bladder. Bladder may refill even if In and Out cath due to the length of the case. If surgeon is not cautious while dissecting the medial umbilical ligament or during the step of dissection around cooper ligament, symphysis area, it will lead to either thermal injury or sharp injury to urinary bladder.

Another scenario which can lead to surgeon getting into trouble will be sliding hernias where urinary bladder is included.

Bladder diverticula: Bladder diverticula are not unusual in patients with prostate problems. Bladder diverticula does not empty well with spontaneous preop voiding, leading to bladder injury.

Need for bowel prep in selective cases: Consider bowel prep if sigmoid colon is part of left inguinal hernia sac and also while planning to repair recurrent inguinal hernia. This will make surgery much easier with less contamination, facilitating primary repair in a well-prepped colon. Incidence is extremely low but it’s real!

Access: Consider using long 8 mm trocars. Arm movements may be restricted if trocar are close to subcostal areas in thinner patients. This will provide better clearance of robotic arms away from patient chest.

Technique: Mesh and suture can be inserted under vision prior to docking.

Exercise extra caution while inserting or taking out needles through 8 mm trocars.

Access into the correct preperitoneal plane will be the key for smooth surgery. Since the tip of robotic grasper is wider, there will be tendency to get into deeper planes leading to difficult and bloody dissection. One of the tricks is to create a small incision in the peritoneum and allow pneumo-dissection to identify the preperitoneal plane.

Cold dissection with judicious use of energy while dissecting the sac and around spermatic cord to avoid thermal injury to testicular vessels.

Sometimes it will be easier to drop the abdominal pressure to 10 mm hg while closing the peritoneal defects to allow for complete closure without tension after mesh insertion.

If barbed suture is used, trim to the peritoneal level to avoid bowel obstruction due to bowel getting stuck to the tail of the barbed suture.

1. Dr Bloomberg inguinal hernia using the hook cautery and 3 instruments.

This is a brief edited hernia case by Dr Bloomberg using 3 instruments and substituting the hook for the monopoly shears.

2. Opening the peritoneal reflection.

Using cold cut using the mega suture cut instead of cautery. This way the case can be completed using 2 instruments.

3. Closing the peritoneum with the same 2 instruments.

Fixation of the mesh in Cooper’s ligament and closure of the peritoneum.

4. Complete hernia repair using 2 instruments

Open peritoneum cold with the suture cut. Dissection, mesh placement and closure with the same 2 instruments. Using occasional bipolar cautery for hemostasis when needed.