Robotic inguinal hernia repair

Abstract

Introduction: Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Robotic surgery adds high definition visualization and articulating instruments. This enhanced dexterity can make laparoscopic hernia repair more refined while obtaining a critical view of the myopectineal orifice that should lead to fewer recurrences and complications. A series of robot-ic, laparoscopic, inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution along with a review of the literature was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery. Materials and Methods: One thousand laparoscopic inguinal hernia operations were performed from April 2012 through March 2020. There were 420 cases of robotic trans-abdominal pre-peritoneal (TAPP) procedures done during that time. Hospital records and follow-up care were prospectively reviewed and data was collected for age, sex, American Society of Anesthesia (ASA) class, and operative time. Follow up was done at two weeks, eight weeks, and 16 weeks following surgery. All patients consented for study. Results: Ninety-four percent (94%) of the patients were male. Age averaged 57.8 years with a range of 18–85 years. ASA averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and GERD being the most common. Body mass index (BMI) was between 19–40.5 averaging 26.6. Sixty-three patients (15%) had an umbilical hernia repair done concomitantly. Operating room (OR) time ranged from 25–140 minutes, with an average of 54.36 minutes, and decreased as experience increased. One patient with a large, left scrotal hernia was converted to open, one patient developed perforated sigmoid diverticulitis seven days postoperative and four recurred indirectly after a direct hernia repair. Urinary retention was the most problematic postoperative occurrence. Conclusions: Robotic inguinal hernia repair is safe and effective. 1) Proper training, including simulators and proctors, is necessary; 2) having the same operating room team and an interested first assistant at the OR table is very helpful; 3) the learning curve is about 50 patients; 4) postoperative narcotics are rarely more than three hydrocodone pills; 4) no fixation of the mesh is necessary, but fibrin sealant was used routinely in these patients; and 5) urinary retention is the most common postoperative issue and is best planned for by knowing the patients urinary history, use of peripheral alpha-blockers, and straight catheterization in the OR at the conclusion of the surgery. OR time was longer than standard laparoscopic herniorrhaphy but decreased with experience. The robotic technique allowed for an excellent view of the myopectineal orifice and appears to have a low complication rate.