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    Robotic Hernia Surgery: A Comprehensive Illustrated Guide
    Robotic Hernia Surgery: A Comprehensive Illustrated Guide
    Robotic Hernia Surgery: A Comprehensive Illustrated Guide
    Ebook612 pages1 hour

    Robotic Hernia Surgery: A Comprehensive Illustrated Guide

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    About this ebook

    This atlas demonstrates how to perform each available extraperitoneal hernia repair via a set of high-quality annotated images showing step-by-step guidance on how to perform the surgery. Robotic extraperitoneal hernia procedures are considered great teaching procedures especially with a dual teaching console. The book bridges the gap between traditional hernia and laparoscopic hernia texts by combining both approaches to create a book with a unique visual approach. Preoperative, intraoperative, and postoperative figures are integrated to highlight the importance of these step-by-step procedures, enhance skill and efficiency, and avoid surgical pitfalls. Detailed descriptive figures accompany step-by-step instructions and include specific anatomical annotations that describe the anatomy and layers of the abdominal wall during hernia procedures.

    Robotic Hernia Surgery provides a comprehensive, insightful and state-of-art review of this field, and serves as a valuable resource for surgeons, surgeons in training, and students with an interest in hernia and robotic hernia surgery.

    LanguageEnglish
    PublisherSpringer
    Release dateJul 3, 2020
    ISBN9783030466671
    Robotic Hernia Surgery: A Comprehensive Illustrated Guide

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      Book preview

      Robotic Hernia Surgery - Omar Yusef Kudsi

      © Springer Nature Switzerland AG 2020

      O. Y. Kudsi (ed.)Robotic Hernia Surgeryhttps://doi.org/10.1007/978-3-030-46667-1_1

      1. Robotic Subxiphoid Hernia Repair: Transabdominal Preperitoneal (TAPP)

      Engin Hatipoglu¹ and Omar Yusef Kudsi²  

      (1)

      Department of General Surgery, Cerrahpasa Faculty of Medicine, Istanbul University–Cerrahpasa/Kocamustafapasa, Istanbul, Turkey

      (2)

      Department of Surgery, Good Samaritan Medical Center, Tufts University School of Medicine, Boston, MA, USA

      Omar Yusef Kudsi

      Keywords

      Subxiphoid herniaM1Transabdominal preperitonealTAPPRobotic ventral hernia repairrTAPP

      Introduction

      Subxiphoid hernias (SHs), are classified as M1 by the European Hernia Society [1]. They usually arise within 3 cm caudal to the ciphoid and are most often encountered as incisional hernias, after sternotomy incisions for cardiac surgery or subcostal incisions for hepatobiliary or foregut procedures [2]. Robotic transabdominal preperitoneal (TAPP) repair for SHs is analogous to the TAPP repair of centrally located hernias, which involves developing a large peritoneal pocket, reducing the hernia sac, closing the hernia defect, placing mesh with wide overlap, and closing the pocket [3]. These hernias' proximity to the costal margin and the diaphragm makes defect closure, adequate mesh overlap, and fixation difficult. Therefore, placing the mesh in the preperitoneal or retrorectus space helps to overcome these technical difficulties. Ensuring a large mesh overlap, even in the absence of mesh fixation, is key to successful robotic TAPP. 

      Procedure: Illustrated Steps

      Figures 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.10, 1.11, 1.12, 1.13, 1.14, 1.15, 1.16, 1.17, 1.18, 1.19, 1.20, 1.21, 1.22, 1.23, and 1.24 illustrate the technical aspects of robotic TAPP repair of subxiphoid hernia (M1) repair.

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig1_HTML.jpg

      Fig. 1.1

      Trocar position in the robotic transabdominal preperitoneal (TAPP) repair for subxiphoid hernia (SH). Three trocars, one for the camera and the others for instruments, are usually sufficient. After docking of the patient-side cart, the EndoWrist® instruments (Intuitive Surgical Inc., Sunnyvale, CA, USA) are introduced to the abdominal cavity: a bipolar fenestrated Maryland (left arm), and a monopolar scissors (right arm), which is later switched with a needle-driver

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig2_HTML.png

      Fig. 1.2

      Initial exploration and adhesions between hernia and omentum

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig3_HTML.jpg

      Fig. 1.3

      With the use of monopolar scissors and a bipolar Maryland, the peritoneum is grasped and cut at least 5 cm from the defect on the side ipsilateral to the trocars

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig4_HTML.jpg

      Fig. 1.4

      Preperitoneal dissection is started by performing a peritoneal incision. The preperitoneal fat underlying the rectus fascia is revealed

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig5_HTML.png

      Fig. 1.5

      Throughout dissection of the peritoneal flap, gentle traction should be applied to avoid tearing of the peritoneum

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig6_HTML.jpg

      Fig. 1.6

      Gentle traction with a sponge (gauze) against the peritoneal flap helps in recognizing the correct dissection line, conrolling minimal bleeding, and minimizing the risk of peritoneal tears

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig7_HTML.jpg

      Fig. 1.7

      The peritoneum forms the inner most layer of the hernia sac, and may be difficult to separate without creating peritoneal tears. Any inadvertent tears should be repaired later using absorbable sutures

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig8_HTML.png

      Fig. 1.8

      The hernia sac is reduced and dissection is continued superior to the defect, allowing for placement of an adequately sized mesh

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig9_HTML.png

      Fig. 1.9

      Retroxiphoid dissection is continued

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig10_HTML.png

      Fig. 1.10

      Left-sided lateral dissection. Preperitoneal dissection should extend 5 cm in all directions from the defect, at least, to provide adequate mesh placement

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig11_HTML.png

      Fig. 1.11

       Right-sided lateral dissection

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig12_HTML.jpg

      Fig. 1.12

      The central tendon of the diaphragm is exposed during cephalic dissection

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig13_HTML.jpg

      Fig. 1.13

      The dissection is carried superiorly to allow for proper mesh overlap over the diaphragm, but care must be taken to avoid violation of the thoracic cavity, central tendon, or pericardium

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig14_HTML.jpg

      Fig. 1.14

      Hernia defect closure is intended to restore abdominal wall anatomy and function, as well as prevent postoperative bulging. The choice of suture material may vary; we perform primary closure of the hernia defect by running a long-lasting, absorbable barbed suture

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig15_HTML.jpg

      Fig. 1.15

      While closing the hernia defect, we prefer to follow the same method used for laparotomy closure : the small-bite technique, taking 5–8 mm bites of fascia and placing stitches every 5 mm in a running fashion

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig16_HTML.jpg

      Fig. 1.16

      Two separate sutures, starting from either end of the defect, meet in the middle of the defect

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig17_HTML.jpg

      Fig. 1.17

      Before tightening the sutures to complete the defect closure, pneumoperitoneum is reduced to 6–8 mmHg and the anesthesiologist is asked to relax the patient’s muscles

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig18_HTML.jpg

      Fig. 1.18

      Pocket size is directly measured by a ruler, which is placed intraperitoneally

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig19_HTML.png

      Fig. 1.19

      Adequate mesh coverage is paramount for successful repair and can be achieved with maintaining 5 cm of overalp in all directctions from the defect

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig20_HTML.jpg

      Fig. 1.20

      The mesh must be secured to prevent migration. A circumferential fascial suture technique with barbed absorbable sutures is used to secure the mesh to the posterior fascia

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig21_HTML.jpg

      Fig. 1.21

      Fixating the mesh with deep sutures around the central tendon of the diaphragm can cause devastating cardiopulmonary injury. A superficial suture fixation method is preferred, away from the central tendon. The use of self-gripping mesh or glue fixation may also be helpful

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig22_HTML.jpg

      Fig. 1.22

      After mesh fixation and control of bleeding, the next step is closing the peritoneal flap with a rapidly absorbable barbed sture, using a bottom-to-top apprach 

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig23_HTML.jpg

      Fig. 1.23

      The risk of intraparietal hernia formation is minimized by using a running short stitch. At the end of the procedure, the peritoneal flap should be examined to ensure that intra-abdominal structures do not come in contact with exposed mesh

      ../images/480003_1_En_1_Chapter/480003_1_En_1_Fig24_HTML.png

      Fig. 1.24

      The trocars are removed and the pneumoperitoneum is released. Long-acting local anesthetic agent is injected at the trocar sites for management of postoperative pain. Skin incisions are sutured

      References

      1.

      Muysoms FE, Miserez M, Berrevoet F, Campanelli G, Champault GG, Chelala E, et al. Classification of primary and incisional abdominal wall hernias. Hernia. 2009;13:407–14.Crossref

      2.

      Hope WW, Hooks WB 3rd. Atypical hernias: suprapubic, subxiphoid, and flank. Surg Clin North Am. 2013;93:1135–62.Crossref

      3.

      Ballecer C, Parra-Davila E. Robotic ventral hernia repair. In: Novitsky YW, editor. Hernia surgery: current principles. Cham: Springer; 2016. p. 273–86.Crossref

      © Springer Nature Switzerland AG 2020

      O. Y. Kudsi (ed.)Robotic Hernia Surgeryhttps://doi.org/10.1007/978-3-030-46667-1_2

      2. Robotic Epigastric Hernia Repair: Totally Extraperitoneal (TEP)

      Hany Takla¹  

      (1)

      Department of General Surgery, Beth Israel Lahey Health, Winchester Hospital, Winchester, MA, USA

      Hany Takla

      Keywords

      Epigastric herniaDiastasis rectieTEPM2 hernia

      Introduction

      According to the European Hernia Society, an M2 (primary epigastric hernia) is an abdominal wall hernia located in the area between 3 cm below the xiphoid and 3 cm above the umbilicus. More commonly, however, epigastric hernias coexist with other midline hernias, including umbilical hernias. Moreover, epigastric hernias are usually seen in the context of rectus muscle diastasis, a condition that commonly affects the abdominal wall in middle-aged women after multiple pregnancies, as well as patients who are overweight or obese.

      Robotic-assisted enhanced-view totally extraperitoneal (eTEP) epigastric hernia repair should be one of the tools in the surgeon’s armamentarium. It has several potential advantages:

      It adequately exposes the retromuscular space, including the midline, which can commonly harbor multiple small defects containing herniated pre-peritoneal fat.

      It allows repair of multiple midline defects as well as rectus muscle diastasis, in theory restoring the functionality of the abdominal wall.

      It allows mesh placement outside of the peritoneal cavity, which allows better mesh incorporation over time and decreases the likelihood of intraperitoneal adhesions.

      For these reasons, the overall interest in the eTEP approach and its adoption for repair of various ventral and incisional hernias has been increasing. In addition, it gives access to the fibers of the transversus abdominus muscle, allowing a transversus abdominis release, which is sometimes needed for larger hernias (typically for defects more than 8 cm in width). Also, separating the posterior sheath from the rectus muscle complex theoretically allows closure of both the posterior sheath and the linea alba without undue tension.

      Procedure: Illustrated Steps

      Figures 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, 2.9, 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23, 2.24, 2.25, 2.26, 2.27, 2.28, 2.29, 2.30, 2.31, and 2.32 illustrate our approach for eTEP epigastric hernia repair, including access, exposure, and tips for efficient repair.

      ../images/480003_1_En_2_Chapter/480003_1_En_2_Fig1_HTML.png

      Fig. 2.1

      (a) Landmarks marked using ultrasound (US) after a transverse abdominis plane (TAP) block is done by Anesthesia. (b) Bilateral linea semilunaris are marked and the span of the rectus muscle bilaterally is measured to ensure adequate space for eTEP. (Typically 8 cm or more is considered adequate.) Midline and diastasis are also visible and can be measured by US

      ../images/480003_1_En_2_Chapter/480003_1_En_2_Fig2_HTML.png

      Fig. 2.2

      Patient positioning, with at least the left arm tucked (or trocar side) to allow more mobility for

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