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Back to Journal »Robotic Surgery: Research and Review» Volume 4

Author Donkor C, Gonzalez A, Gallas MR, Helbig M, Weinstein C, Rodriguez J

Published on May 5, 2017 2017 Volume: 4 pages 57-67

DOI https://doi.org/10.2147/RSRR.S101809

Single anonymous peer review

Editor approved for publication: Dr. Masoud Azodi

Charan Donkor,1,2 Anthony Gonzalez,1,2 Michelle R Gallas,3 Michael Helbig,2 Corey Weinstein,2 Jaime Rodriguez2 1 Department of General and Bariatric Surgery, South Florida Baptist Health Center, Miami, Florida, USA; 2Florida International University , Herbert Wertheim College of Medicine, Miami, Florida, USA; 3 Population Health and Outcome Research, Research and Funding Center, South Florida, Miami, Florida, South Florida Baptist Health Center Abstract: Hernia The surgical treatment of the patient continues to evolve with the development of surgery. Part of the fascination with hernia surgery is due to its popularity and the variety of treatment options. The goal of minimally invasive hernia surgery is to perform a robust repair with minimal complications, and new robotic technology is being developed to treat complex abdominal hernias, and promising results have been achieved. This review focuses on inguinal, ventral, and incisional hernias and their outcomes, and discusses traditional laparotomy, laparoscopic, and robotic techniques. It also outlines the popularity and advantages of minimally invasive hernia surgery. We emphasize our experience in these operations, especially robotic hernia repair, because it involves ventral incision and inguinal hernia repair. We concluded that the robotic platform proved to be beneficial for hernia repair. Many studies have shown that its feasibility is comparable to the results of standard laparoscopy, and some studies have shown better results, including shortening the length of hospital stay without significantly increasing costs. Robotic options for hernia repair have led to an increase in minimally invasive hernia repair, a number that has stagnated for the past decade. As more and more surgeons gain training and experience and the greater availability of robotic platforms, we expect to see more minimally invasive hernia repairs. Keywords: hernia, hernia repair, ventral, incision, robot, laparoscopy

Since the beginning of human history, the concept of hernia and its treatment has existed. 1 The treatment of hernia has progressed with the development of surgery, and new prosthetic technology has promoted the development of hernia repair. Part of the fascination with hernia surgery is due to its popularity and the variety of treatment options. However, hernia repair is not without the risk of complications. The goal of hernia surgery is to perform strong repairs while minimizing complications. Minimally invasive hernia surgery has a lower risk of treating this problem, and the risk of common complications encountered with open surgery is lower. The new technology of minimally invasive hernia surgery originated from the previous open method, and now more complex abdominal hernias can be handled by robots. These results are promising for patients with complex abdominal hernias who may require strong anatomical repair but can still benefit from minimally invasive methods. Abdominal wall hernia is defined as the protrusion of intra-abdominal tissue through a defect in the abdominal wall, called abdominal hernia. A hernia can be an enlargement of a natural anatomical defect (hiatal hernia or inguinal hernia), or it can be the development of a new defect in the damaged tissue. For the purpose of this discussion, we will focus on inguinal, ventral and incisional hernias. The categories of abdominal hernias include umbilical hernia, epigastric hernia and spigelian hernia.

In this review, we discuss traditional open and laparoscopic hernia repair procedures and their results. The prevalence and advantages of minimally invasive hernia surgery are summarized. We emphasize our experience in minimally invasive hernia surgery, especially robotic hernia repair, because it involves ventral incision and inguinal hernia repair.

Open hernia repair is regarded as a "bread and butter" operation for general surgeons, so its management is of great significance. Although hernia is one of the most common diseases among doctors, their treatment methods may vary from surgeon to surgeon due to lack of consensus on management. 2 The hernia is repaired by traditional open surgery or minimally invasive techniques. Minimally invasive hernia surgery has a similar recurrence rate and fewer complications, such as infection at the surgical site. 3 Despite the advantages of minimally invasive surgery, traditional open hernia surgery still seems to be the main treatment method, because most abdominal wall hernias are repaired in this way. Having said that, most abdominal and inguinal hernias are still repaired using open techniques. 3,4 Due to the technical difficulty, the learning curve of minimally invasive hernia repair is very steep, which is the main factor leading to the failure of the operation. Such a low number. With the advent of robotic platforms, this number is still increasing. The Da Vinci robotic platform allows surgeons to perform more technically difficult operations in a minimally invasive manner because it has better visualization and wrist movement capabilities. Robotic surgery now also plays an important role in complex abdominal wall hernias. Open complex hernia surgery has a significant complication rate, and the surgical technique has not changed much in the past 20 years. With the development of technology, the material bioscience of mesh prosthesis is also constantly developing. When discussing the current trend of robot-assisted hernia surgery, the two go hand in hand.

Another component of this controversial topic is grid selection. In addition to biological agents, polypropylene and polyester are the most commonly used materials for making mesh prostheses. The manufacturing process starts with raw materials processed into polypropylene or polyester pellets. These are squeezed into fibers and then woven into a specific pattern set in advance. This model is very important for the characteristics of the final product. The ideal engineering prosthesis should be strong, flexible, non-allergenic, non-carcinogenic, and can stimulate fibroblast activity. In the development of prostheses, elasticity, stiffness, burst strength, tensile strength and compliance are parameters that have been thoroughly studied. These may be related to density, weight and pore size. If necessary, the net can also be coated with different materials for the purpose of intra-abdominal placement. Therefore, many types are possible, but few studies have strong evidence for the best mesh prosthesis. Many surgeons may not realize the nuances between them, and their preferences may be based on other factors, such as availability and cost. For example, a hospital may provide contract products specifically to certain companies. Decisions about which products are available are usually made by non-clinical managers or a small group of surgeons in the hospital. This usually keeps costs to a minimum, but limits the surgeon's options and therefore the experience with other products.

When selecting a mesh, the pore size, density and tensile strength are important characteristics. 5 There is ample evidence that the use of lightweight mesh is not suitable for "bridging" repair of abdominal hernias, and light mesh may not be suitable for inguinal hernias with large direct defects. Adhesion formation is also an important factor, especially when dealing with subsequent abdominal surgery. 6 There are many studies on adhesion barriers; however, the evidence is not clear which barrier is the best. When choosing a grid, you should consider all of these points discussed earlier. In addition, surgeons should feel comfortable, familiar, and confident about the products they decide to place in the patient's abdominal cavity.

In the past 20 years, the increase in grid usage has helped reduce the recurrence rate. The purpose of patch fixation is to fully adhere the patch while allowing it to blend into the abdominal wall tissue with minimal postoperative pain. The result is to prevent the hernia from recurring and avoid chronic pain. Nails, puncture sutures, glue, and self-adhesive mesh are currently available options for surgeons. Due to the variety of methods available, there is little standardization of mesh fixation, partly due to the lack of strong evidence and the fact that hernia technology is constantly changing. The pain is related to nails and transfascial fixation sutures, so there is motivation to build compliance in other ways. Surgeons are concerned that the use of TMF for laparoscopic inguinal hernia repair will bring significant risks of pubic osteitis, nerve entrapment, and chronic inguinal pain. 7 A meta-analysis of TMF and plastic mesh fixation (GMF published in 2013) found no difference in the incidence of surgical time, perioperative pain, postoperative complications, recurrence, and length of hospital stay. However, there are differences in the development of chronic groin pain, and the incidence of chronic pain in the GMF group was significantly lower. However, in this comparison, only four studies have contributed to the analysis, and these studies have moderate to significant heterogeneity. 7 In general, it seems that the use of glue in inguinal hernia repair is equivalent to the use of nails. 8,9 In abdominal hernias, puncture sutures and double crown nail techniques seem to be the safest for mesh adhesion. 10 In robotic abdominal hernia repair, the mesh can be fixed in any of these ways, and it can even be sutured continuously or intermittently to achieve similar results. 11 Self-adhesive patches have been described in inguinal hernias, with or without additional fixation, the initial results are encouraging. 12 Similar to patch selection, the choice of fixation ultimately depends on the surgeon and on their personal experience. As more studies are published, standardization may be achieved.

Open inguinal hernia repair is still the mainstay of inguinal hernia repair, and most selective inguinal hernia repairs are done through traditional open techniques. Modern treatment of inguinal hernia begins with a primary repair under tension. Bassini is known for performing anatomical repairs to the posterior wall of the inguinal canal. 13 He collected data on more than 200 patients and tracked their surgical results. Followed by Lichtenstein and Shulman1, they described the most popular technique to date; mesh tension-free repair. In his technique, a plug is placed in the outer ring and a patch is placed on the floor of the groin. The mesh is then sutured to the joint tendon, shelf edge, and pubic tubercle. Lichtenstein and Shulman1 promoted this technique by publishing their first 1,000 cases with excellent results. This completely changed the hernia repair, so the recurrence rate decreased. Although there are various mesh prostheses, the actual technology has not changed significantly. Complications include wound infection, postoperative pain and hernia recurrence. Compared with minimally invasive hernia repair, wound infections are reduced, and postoperative pain and recurrence rates are often similar to those of open surgery. 3

Laparoscopic repair of an inguinal hernia was first described in 1979, when he closed the cyst neck laparoscopically. 2 The most commonly used techniques are divided into transabdominal preperitoneal (TAPP) approach or total extraperitoneal (TEP) approach, including the placement of a net. The two techniques have similar results in terms of operation time, postoperative pain, return to work, and recurrence. 14 It has been reported that TAPP has some advantages in patients with contralateral and incarcerated hernias, because direct observation of the intestine is important. Compared with open hernia repair, laparoscopic repair can reduce postoperative pain and wound infection, and return to work earlier. 3

Although laparoscopic inguinal hernia repair has these advantages, the standard practice is in sharp contrast to laparoscopic cholecystectomy, which has become the standard of care since the first case was implemented in 1985. Scholarship for minimally invasive surgery. Despite this advanced training, not all surgeons who have received scholarship training perform minimally invasive inguinal hernia repair in their practice. Part of the difficulty comes from technical aspects, such as the small working space and the difficulty of laparoscopically handling the mesh. In addition, the anatomical considerations are different because the landmark structures are visualized from different vantage points. It may take about 20 cases to become familiar with this anatomy and stabilize the operation time. 16 However, laparoscopic repair should be the choice for bilateral inguinal hernias and recurrent hernias. Unilateral hernia repair is acceptable, but there is controversy.

Since laparoscopic inguinal hernia repair has not been widely used, the robotic platform has become an indispensable part of minimally invasive inguinal hernia repair. The surgeon’s wrist movement, three-dimensional visualization, and excellent ergonomics help make this technique a more accessible technique than laparoscopic techniques. The urologist reported the first report of robotic inguinal hernia repair while performing radical prostatectomy. 17,18 Since these initial reports, the official robotic inguinal hernia repair by general surgeons has been published. Escobar Dominguez et al19 published his series of 78 patients undergoing robotic inguinal hernia repair, and the results showed a similar cost impact. Waite et al.20 published a smaller series of robotic TAPP and laparoscopic TAPP. The results showed that postoperative pain was improved, the operation time increased, and the cost was similar.

Cost control is a concern of all those who take care of patients. In the first impression, people may think that robotic hernia repair costs are too high. In further inspections, in most cases, the robot has been purchased for majors such as urology and gynecology. Compared with its laparoscopic counterpart, surgeons can significantly reduce the cost of surgery by eliminating the balloon spacer for those who practice standard laparoscopic TEP. For surgeons who use stapling devices, sutures or self-adhesive nets are reasonable choices. In robot repair, TAPP is more common, because in this technique, there is a larger working space, which makes the procedure technically easier. This is more prominent in smaller patients. Overall, due to the technical ease of use of the robotic platform, we can expect an increase in surgeons performing minimally invasive hernia surgery. This translates into benefits for patients, because minimally invasive hernia repair has multiple benefits in both the short and long term.

Surgical technique-robotic inguinal hernia repair

The robotic platforms Si and Xi are the best choices for robotic inguinal hernia repair. When using the Si platform, the placement of the cart for docking is very important. On the contrary, the Xi platform allows side docking in all cases. Enter the abdominal cavity through an incision around the umbilical cord. If the patient had a midline incision before and the midline incision is unsafe, use the Palmers point (upper left quadrant) instead. Depending on the surgeon's choice, access to the peritoneal space is achieved by placing a Veress needle, an optical trocar, or using Hassan technology to cut directly. If the Hassan technology is used, a trocar compatible with the robot platform used is required. It is standard to blow in 15 mmHg with CO2. The remaining bilateral robotic trocars were introduced under direct laparoscopic vision. These are usually placed at the level of the umbilicus or slightly higher, depending on the patient's abdominal circumference. For smaller patients, we place the trocar closer to the head to ensure sufficient working space (Figure 1). On the da Vinci Si platform, the robot cart can be docked between the legs of the lithotomy patient or with the patient lying on his back (Figure 2). The position we chose is the supine position, the moderate Trendelenburg position. The docking does not need to be done on the same side of the hernia to be repaired. Regardless of the position of the robot cart, parallel or side docking can access both groin areas (Figure 2).

Figure 1 Figure 1 Schematic diagram of trocar placement, illustrating the head orientation (A) and an example of the actual head trocar orientation (B).

Abbreviations: MCL, midclavicular line; SUL, spinal cord.

Figure 2 The side docking with the Da Vinci Si robot allows access to the bilateral groin area.

The Xi model allows docking from either side. TAPP remains the method of choice for robotic inguinal hernia repair. The anatomy of this method is different from the traditional open method. Before opening the peritoneum, the umbilical ligaments, external iliac vessels, and gonadal vessels should be identified. We start with the peritoneal incision between the anterior superior iliac spine and the medial umbilical ligament. Opening the peritoneum and dissection can be performed with scissors or hooks with cautery. The container sealing device of the robot can also be used for this purpose, but at a higher cost. The cost of the instrument must be considered, so we strive to limit the use of the instrument to a combination of three instruments. For example, a typical robotic inguinal hernia might use grasping forceps, scissors with cautery, and suture cutting needle drivers. The incision must be wide enough to enter the Cooper’s ligament and lateral abdominal wall, and large enough to fit comfortably in a mesh of the right size. The flap size is usually estimated to fit snugly against the mesh. A flap that is too large will increase the operation time and make the mesh easier to move, while a flap that is too small and anatomy will not be able to comfortably place a mesh of a suitable size. In the latter case, the grid may roll up at the lower edge, which may cause recurrence.

In our technique, once our flap is created, we will focus on dissecting the Cooper ligament located outside of the pubic symphysis. This will help identify the pre-peritoneal anatomy. The Cooper's ligament is first identified by dissecting the medial space. This is usually done before the hernia is resolved, as it is a useful sign, especially when the hernia sac is large and obscures the anatomical area. Once the Cooper ligament is identified and clearly visible, we encourage lateral dissection of the preperitoneal space. This will ensure easier identification of the spermatic cord, vas deferens and other important structures (Figure 3). The hernia sac must be completely separated from the spermatic cord to avoid recurrence of the hernia. In the case of a large inguinal scrotal hernia that may become difficult to dissect, the sac can be transected and left in place, carefully closing the peritoneal defect. If it is decided to ligate the sac, the narrowest point of the sac is the best, as this will reduce the size of the peritoneal valve defect that needs to be closed. After the dissection is complete, the grid can be placed in an appropriate position. The grid can be delivered by an assistant at the bedside through an 8 mm robotic trocar at the beginning of the operation before the robot is docked or at an appropriate time. When placed at the beginning of the operation, we placed our mesh and sutures at the entrance of the pelvis, where it can be seen but does not hinder the anatomy. When using self-adhesive patches, suture fixation is required when the direct defect is large. The mesh spans the space from the pubic tubercle to the lateral wall of the abdomen, covering indirect and direct defects. For fixation, non-absorbable sutures or nails are placed on the inside and outside of the Cooper’s ligament and the upper abdominal wall of the abdominal blood vessels. Self-adhesive mesh must be placed carefully and strategically to prevent the need to "untie" the mesh and reapply it. We prefer to roll the grid from the inside to the outside starting from the Cooper ligament. This ensures that there is enough inside space to cover when positioning. Adequate coverage is the key, as this can reduce recurrence (Figure 4). In addition to this technique, a large direct defect can be sutured with barbed sutures. This can be used to prevent the grid from cracking due to large defects.

Figure 3 Schematic diagram of the anatomy of the groin.

Note: The top arrow shows the upper abdominal blood vessels, and the bottom arrow shows the vas deferens within the spermatic cord.

Figure 4 After the hernia sac is reduced, place the mesh in the proper direction and fully cover the direct and indirect spaces.

The peritoneal flap is then closed with barbed absorbable sutures or permanent sutures. The use of barbed suture facilitates this closure because it maintains "tension" during the re-approach. There are some cases of intestinal obstruction caused by the adhesion of barb sutures to the intestine after surgery. 21 Since the long exposed suture segment may cause the intestine to be clamped, we may "tighten" the suture as much as possible in order to bury it in the peritoneum (Figure 5). In general, barb sutures are considered safe in intra-abdominal surgery; however, surgeons should be aware of this uncommon complication.

Figure 5 Embedding the barbed suture in the peritoneum can ensure adequate closure and prevent complications such as bowel compression.

Abdominal wall and anterior incision abdominal wall hernia

Anterior incision and ventral abdominal wall hernia are a common pathology. Incisional hernia occurs after previous surgery, and the incidence is approximately 15-20%. It is estimated that approximately 400,000-600,000 incisional hernias are repaired each year in the United States. 22,23 Since the beginning of surgery, the risk of incisional hernia has increased year by year. Treatment is surgery. Traditionally, these hernias are repaired as open surgery, regardless of whether a mesh prosthesis is placed. There are many ways to repair these hernias, and there are many prostheses to choose from. Surgeons ultimately decide which technique is best for their patients. There are various techniques for repairing hernias. Therefore, surgical treatment lacks standardization; therefore, there is controversy when discussing the best technique, patient selection, and choice of prosthesis used. The research on this topic comes from aggregated data, so the interpretation can be confusing.

The mesh during the repair process can be placed anatomically in different positions, which has always been a topic of debate (Figure 6). The grid placed above the fascia is called an "onlay". The net placed between the posterior rectus sheath and the rectus muscle refers to sublayer placement. Finally, when the mesh is resting on the peritoneum, it is considered to be in the cushion position. A large Cochrane review24 compared onlay and sublayer grid placement, but failed to show the advantages of either technique. Patch repair is associated with fewer recurrences, and the recurrence weight of standard weight patches is lower than that of lightweight patches. 24 We do know that for complex large abdominal wall hernias, the incidence is very high. If they can be repaired by minimally invasive methods, the risk for patients can be significantly reduced. Patient selection is the key to this method, because multiple previous abdominal surgeries, previous mesh placement, and large hernia defects may be relative contraindications to minimally invasive methods. According to the surgeon’s experience, larger defects may show better results through open techniques. For patients with complex large abdominal wall hernias, a mainly closed defect may be the best choice for long-term results. 25 With the advent of robots, it can now be performed minimally invasively, and the results are promising. The morbidity of large open incisions is removed, and the strength of hernia repair is preserved. In order to clearly illustrate this point, we first discuss open abdominal hernia and incisional hernia repair.

Figure 6 The contours of the different anatomical positions where the grid is placed.

Open hernia repair (OVHR) with or without mesh

Traditional open hernia repair is described as using or not using mesh. It has been shown that mesh placement reduces the recurrence rate; therefore, in the case of a suitable mesh, a prosthesis should be used. 24 The location of the grid is different, which increases the diversity of the technology. Onlay refers to placing the mesh directly on the top of the fascia directly below the subcutaneous tissue. Although this is not the most popular, it has proven that this placement method is as effective as other methods. 26 The cushion net is placed close to the peritoneum. It is the best choice when the overlap reaches 4-5 cm. The most typical method of cushion placement is to suture the mesh along the circumference of the peritoneum to the underside of the fascia while achieving an overlap of 4-5 cm. The fascia is then usually enclosed on top of the net. This can be done with or without component separation. Rives et al.27 described the sublay technique of placing the mesh on the back of the muscle. If necessary, this can also be combined with component separation to get close to the edge of the fascia. Whether the location of the grid affects the outcome is a controversial topic: sublay has been shown to outperform the bottom layer in terms of recurrence. 28 However, compared with onlay, sublay is also claimed to have no advantage over sublay technology, while others have shown significant advantages. 28,29 The controversy continues. The trend of ground-level repair is common in the United States, while in Europe, ground-level repair is standard.

Laparoscopic ventral and incisional hernia repair (LVIHR) with mesh

Laparoscopic abdominal hernia repair was first described in the early 1990s as a bridging peritoneal inlay patch (IPOM) repair. Metal nails were initially used to fix the mesh, and later a transfascial fixation suture was implemented, which reduced the recurrence rate. 30 LVIHR is most commonly used for laparoscopic IPOM repair. The described technique is very standard and includes the placement of a mesh prosthesis to "bridging" the hernia defect. Important evidence-based technical points include mesh overlap, the use of transfascial fixation sutures, and the "double crown" technique for positioning nails. Compared with open hernia repair, shorter hospital stay, faster return to work, and significantly lower infection rate are the advantages of LVIHR. 31,32 Another advantage of laparoscopy is the ability to evaluate the entire fascia, so that concurrent hernias can be detected and repaired at the same time. Even if the incidence is reduced, only 20-27% of abdominal hernias are repaired by laparoscopy. 4 Usually, in LVIHR, the fascial defect is not closed. Through this "bridging repair", larger defects tend to have a higher recurrence rate. The disadvantages of LVIHR include bulging of the patch, and more acute and chronic pain. 33 In addition, the placement of intraperitoneal patches increases the risk of enterotomy during subsequent abdominal surgery. 34 It is believed that the bridge repair is not very strong, because the pressure exerted by the oblique muscle on the mesh can cause recurrence. In addition, when the fascia is close to the midline, the force distribution is more even, so the repair force is stronger. It has been shown that the success rate of hernia repair is higher when the defect is sutured and the mesh is placed. 25 This method is rarely performed laparoscopy and can only be performed by the most skilled minimally invasive surgeons. Therefore, the benefits of LVIHR and the benefits of traditional open technology may allow us to achieve better results in these patients. This was not a common practice until recently before the use of robotics in hernia repair.

With the advent of robotics, larger and more complex hernia repairs are being performed in a minimally invasive manner. The minimally invasive robotic platform promotes the benefits of fascia closure, posterior rectus placement of the mesh, rectus release and intraperitoneal suture of the mesh. The goal of robotic hernia repair is to obtain the same quality of hernia repair as achieved through open technology, while eliminating its perioperative morbidity. Although the fascia closure and the location of the grid are controversial, robot-assisted surgery provides minimally invasive hernia surgeons with more options than standard laparoscopic surgery. IPOM and IPOM-plus (i.e. IPOM with internal fascia closure) are usually two options for minimally invasive hernia surgeons. Allison et al35 studied robotic laparoscopic incisional hernia repair and internal fascia closure. This study investigated 13 small and medium-sized abdominal hernia patients with an average fascial defect of 37.39 cm2. Use O-shaped absorbable sutures to close the defect. The average operation time is 131 minutes, and the incidence rate is 13%. The average hospital stay was 2.4 days, and only one patient had a recurrent hernia. Although this is a small study with a short follow-up of 23 months, it shows the feasibility of robot-assisted hernia repair with comparable results. 35 Gonzalez et al11 described robotic ventral hernia repair for fascial closure and compared it with a laparoscopic cohort. In this method, the fascia is closed by the robot without removing the capsule. Then suture the intraperitoneal net to the position of the intraperitoneal liner. In this repair, the safety and effectiveness are obvious. It is worth noting that the robot group that received fascia closure had a lower recurrence rate. Early research on robot-assisted hernia repair usually involves small to medium-sized hernias. Warren et al36 described his retromuscular and transrectus abdominis (TAR) lysis and repair and compared it with traditional laparoscopic repair. Hernias are usually large, with an average area of ​​88 cm2. In this technique, the posterior fascia is cut to the half-moon line, and then the rectus muscles are released if necessary. Even for large defects, the defect can be closed, and the mesh can be removed from the intra-abdominal compartment by placing the mesh behind the rectus abdominis and anterior to the peritoneum. The goal when repairing a hernia is to have an overlap of at least 5 cm. In this single-institution study, 103 patients who underwent laparoscopic ventral hernia repair were compared with 53 patients who underwent robotic ventral hernia repair. After adjusting for age, demographics, and hernias, it was found that the robot achieved fascia closure 96.2% of the time, compared to 50.5% of the laparoscopic technique. However, the operating time of the robot is much longer, with an average operating time of 245 minutes compared to 122 minutes. Robotic technology is better than laparoscopic surgery in terms of postoperative anesthesia requirements, the required morphine equivalent is reduced by 0.4 times, and the average hospital stay is reduced by 1 day. In contrast, the incidence of seromas in the robotic cohort was higher, at 47.2% and 16.5%, respectively. 36 Liang et al.37 published a systematic review of best practices for abdominal hernia repair. When all experts agree, the expert group’s response is used to reach a consensus. Fascia closure and minimally invasive techniques have evidence-based benefits, so robotics can help facilitate this. The focus of the debate is whether the capsular bag should be removed and the location of the mesh. Some people have mentioned adding a sac at the closure of the fascia to reduce the formation of seromas; however, there is no data to support this so far. 36 Regarding the positioning of the grid, the data is variable, and some studies have shown that the sublayer position is the best. 37 Ultimately, this decision depends on the surgeon performing the operation. If the surgeon thinks that the sub-recumbent position is better for a particular patient, he can choose a robotic posterior rectus repair.

Surgical technique: robotic ventral incisional hernia repair

In robotic abdominal hernia repair, the abdominal access is obtained as described above. The ports are placed in a fairly horizontal position to provide as much work space as possible (Figure 7). In very large hernias, dual docking techniques may be required. Therefore, additional ports can be placed in the same position on the other side (Figure 8). Any adhesions that would prevent anatomy are removed by laparoscopy. We start the dissection of the posterior rectus by incising the contralateral posterior rectus sheath. We usually use hot shears for this part of the anatomy. If the defect deviates from the midline, we can enter the posterior rectus space from the inside and work on the outside. For central hernias, we usually cut the posterior rectus sheath from the midline (Figure 9). The double docking technique performs lateral dissection on both sides. Dissecting 5 cm above and below the edge of the hernia defect, a mesh of appropriate size can be placed. The choice of mesh depends on the surgeon. The outer boundary is the outer perforating blood vessels, and the dissection is performed on the inner side of these vessels. If possible, remove the capsule (Figure 10). In some cases, we choose to leave the capsule and close it with the fascia. Once fully dissected, we approximated the edge of the fascia with the running barbed suture (Figure 11). Use two sutures from both ends. If the defect may be too large for comfortable access to the fascia, heat shear or a vascular closure device can be used to release the transversus abdominis muscle. The transversus abdominis muscle should be released on the inside of the lateral perforating vessels. Once the muscle is cut to the half-moon line, the lateral perforating vessels can be seen. Then rest the mesh on the rectus muscle, which can be fixed in place with nails or fixed sutures or glue (Figure 12). Self-adhesive nets are also an option. The posterior rectus sheath and peritoneum are closed on the mesh and are not visible or in contact with the contents of the abdominal cavity (Figure 13).

Figure 7 The horizontal placement of the ports maximizes the working area.

Abbreviations: MCL, midclavicular line; SUL, spinal cord.

Figure 8 Large anterior incisional hernia defect.

Figure 9 Anatomical capsule of posterior rectus muscle.

Figure 10 The complete circumferential anatomy of the capsule.

Figure 11 The edges of the fascia are approximated with barbed sutures.

Figure 12 A fixator, puncture suture, glue or a combination is used to fix the net on the rectus muscle.

Figure 13 The posterior rectus sheath and peritoneum are closed, and the mesh is fixed in the posterior rectus space and kept in the abdominal cavity.

If the surgeon prefers padding or does not want to place the mesh in the pre-peritoneal position, the aforementioned technique will be different. After entering the abdominal cavity as described above, remove all adhesions in the abdominal cavity and empty the sac. The capsule can also be removed. Use interrupted sutures or continuous barbed sutures to complete the closure of the defect. The mesh is then placed on the repair site with at least 5 cm overlap in all directions. The fixation of the mesh can be accomplished by circumferential barbed sutures, interrupted sutures, tacks, or any combination of these.

Regardless of the technique used, intraoperative placement of an abdominal adhesive with an extra roll of gauze in the previous location of the hernia may help reduce the chance of seroma or hematoma formation. This pressure dressing should be prescribed to the patient and worn at all times within 1 month.

Facts have proved that the robotic platform is conducive to hernia repair. Many studies have shown that its feasibility is comparable to the results of standard laparoscopy, and some studies have shown better results, including shortening the length of hospital stay without significant increase in costs. For experienced robotic hernia surgeons, complex abdominal wall reconstruction is a reasonable choice. Technical advantages include better visualization, improved ergonomics, and wrist movement, making anatomy easier. Robotic options for hernia repair have led to an increase in minimally invasive hernia repair, a number that has stagnated for the past decade. With more availability of robotic platforms and more surgeons gaining experience and training, we expect to see more minimally invasive hernia repairs.

The authors report no conflicts of interest in this work.

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