Current perspectives in robotic hernia repair

Abstract

The surgical treatment of hernias has developed throughout the evolution of surgery. The fascination with hernia surgery is in part driven by its prevalence and by the variety of treatment options. Minimally invasive hernia surgery has a goal of a robust repair with minimal complications, and new robotic techniques are being developed in complex abdominal wall hernias with promising results. This review focuses on inguinal, ventral, and incisional hernias and their outcomes with a discussion on the traditional open, laparoscopic, and robotic techniques. The prevalence of minimally invasive hernia surgery and its advantages are also outlined. We highlight our experience in these procedures, specifically robotic herniorrhaphy, as it pertains to ventral incisional and inguinal hernia repair. We conclude that the robotic platform is proving to be a benefit to hernia repair. Many studies are showing its feasibility and comparable results to standard laparoscopy, and some have shown improved results, including shorter hospital stay without significant increases in cost. The robotic option of hernia repair has resulted in an increase in minimally invasive hernia repair, a number that has remained stagnant for the last decade. With more surgeons gaining training and experience and greater availability of the robotic platform, we expect to see greater numbers of minimally invasive hernia repair.

Keywords: hernia; hernia repair; incisional; laparoscopic; robotic; ventral.

Figure 1

Schematic representation of trocar placement illustrating cephalad orientation (A) and example of actual cephald trocar orientation (B). Abbreviations: MCL, midclavicular line; SUL, spinoumbilical line.

Figure 2

Robot side docking with da Vinci Si allows access to bilateral inguinal regions.

Figure 3

Illustration of inguinal dissection. Notes: Top arrow shows the epigastric vessels, and the bottom arrow shows the vas deferens within the spermatic cord.

Figure 4

Once the hernia sac has been reduced, the mesh is placed in proper orientation with adequate coverage of direct and indirect space.

Figure 5

Burying the barbed sutures within the peritoneum ensures adequate closure and protects against complications such as bowel entrapment.

Figure 6

Outline of different anatomical positions for mesh placement. Note: © The Author(s) 2012.

Figure 7

Lateral placement of ports maximizes the work field. Abbreviations: MCL, midclavicular line; SUL, spinoumbilical line.

Figure 8

Large anterior incisional hernia defect.

Figure 9

Retrorectus dissection of the sac.

Figure 10

Complete circumferential dissection of the sac.

Figure 11

Fascial edges are approximated with a running barbed suture.

Figure 12

Tackers, transfixation suture, glue, or a combination is used to secure the mesh against the rectus muscle.

Figure 13

The posterior rectus sheath and peritoneum are closed securing the mesh in the retrorectus space and keeping it out of the intra-abdominal compartment.