Telerobotic laparoscopic repair of incisional ventral hernias using intraperitoneal prosthetic mesh

Abstract

Laparoscopic ventral hernia repair shortens the length of hospital stay and achieves low rates of hernia recurrence. The inherent difficulties of performing advanced laparoscopy operations, however, have limited the adoption of this technique by many surgeons. We hypothesized that the virtual operative field and hand-like instruments of a telerobotic surgical system could overcome these limitations. We present herein the first 2 reported cases of telerobotic laparoscopic ventral hernia repair with mesh. The operations were accomplished with the da Vinci telerobotic surgical system. The hernia defects were repaired with dual-sided, expanded polytetrafluoroethylene (ePTFE) mesh. The mesh was secured in place with 8 sutures that were passed through the abdominal wall, and 5-mm surgical tacks were placed around the circumference of the mesh. The 2 operations were accomplished with total operative times of 120 and 135 minutes and total operating room times of 166 and 180 minutes, respectively. The patients were discharged home on postoperative days 1 and 4. The surgeon sat in an ergonomically comfortable position at a computer console that was remote from the patient. Immersion of the surgeon within the 3-dimensional virtual operative field expedited each stage of these procedures. The articulation of the wristed telerobotic instruments greatly facilitated reaching the anterior abdominal cavity near the abdominal wall. This report indicates that telerobotic laparoscopic ventral hernia repair is feasible and suggests that telepresence technology facilitates this procedure.

Figure 1.

Three trocars are used in this procedure. A 12 mm disposable trocar for the stereo-optical telescope is inserted on the right anterior axillary line at the level of the umbilicus. Two 8 mm reusable trocars are inserted on the right mid-clavicular line. The right and left-hand instruments of the robot are inserted through these trocars.

Figure 2.

The tower that suspends the three robotic arms is brought in from the left side of the patient. It approaches the surgical table at a 45-degree angle from the foot of the table.

Figure 3.

The small intestine was densely adherent to the anterior abdominal wall in Patient 2. Cadiere graspers in the robot's right hand provided traction on the bowel. Scissors in the robot's left hand divided the adhesions.

Figure 4.

The surgeon sits at the surgeon's console. The console is separated from the patient but required by the FDA to be within the same operating room. The console houses the robot's computer and binocular stereoscopic video system. The surgeon places his/her hands into the “master” (insert), which translates the surgeon's hand motions into the motions of the telerobotic surgical instruments.

Figure 5.

The bed-side assistant surgeon used a suture passer (Karl Storz Endoscopy America, Santa Barbara, California) to pull the #,0 Gore-Tex suture (W. L. Gore & Associates, Flagstaff, Arizona) through the abdominal wall. The surgeon used a Cadiere grasper and needle holder to place the suture in the suture passer.

Figure 6.

After the eight transabdominal wall sutures are tied, the edges of the mesh are secured to the abdominal wall with 5 mm tacks (Autosuture ProTack, Autosuture, Norwalk, Connecticut). This prevents bowel from migrating between the mesh and the abdominal wall. The mesh sits flatly against the abdominal wall covering the incisional hernia of Patient 2. The intraabdominal pressure is 6 mm of mercury during this portion of the operation.

Figure 7.

Patient 1 at the end of the operation. Plastic dressings cover the three trocar sites on the right side of the abdomen and the eight 2 mm stab incisions through which the transabdominal sutures were passed and then tied. The margins of the two hernia defects are marked with small x's. Two concentric ellipses encompass the two defects. The outer ellipse marks the 2-inch overlap of the mesh around the hernia defects.