From the Guidelines
Robotic inguinal hernia repair with mesh is a recommended approach for patients with intestinal incarceration and no signs of intestinal strangulation or concurrent bowel resection, as it is associated with a lower recurrence rate and no increase in wound infection rate, as supported by the guidelines 1. The procedure involves several key operative steps, starting with patient positioning in the supine position with arms tucked and general anesthesia administration.
- Three ports are typically placed: a 12mm camera port at the umbilicus, and two 8mm robotic ports placed laterally in the midclavicular line.
- After establishing pneumoperitoneum, the robot is docked, and the surgeon identifies anatomical landmarks including the medial umbilical ligament, inferior epigastric vessels, and the hernia defect.
- The peritoneum is then incised 2-3cm above the hernia defect, creating a peritoneal flap, and careful dissection of the preperitoneal space follows, with identification and preservation of the vas deferens and testicular vessels in male patients.
- The hernia sac is reduced, and any lipoma of the cord is excised, and a properly sized polypropylene mesh (typically 10x15cm) is introduced through the camera port and positioned to cover the myopectineal orifice, ensuring at least 3-5cm overlap beyond the defect margins, as recommended for clean surgical fields (CDC wound class I) 1.
- The mesh is secured with absorbable tacks or sutures, avoiding the "triangle of pain" laterally and "triangle of doom" inferiorly to prevent nerve injury or vascular damage.
- The peritoneal flap is then reapproximated with a running suture to prevent mesh exposure to bowel, and the pneumoperitoneum is released, ports are removed, and incisions are closed. This approach offers advantages of enhanced visualization, improved ergonomics, and potentially less postoperative pain compared to conventional laparoscopic techniques, and is in line with the guidelines that recommend the use of mesh in clean surgical fields (CDC wound class I) for a lower recurrence rate and no increase in wound infection rate 1.
From the Research
Operative Steps for Robotic Inguinal Hernia Repair with Mesh
The operative steps for robotic inguinal hernia repair with mesh involve several key technical steps, including:
- Preoperative planning and patient selection 2
- Use of a robotic transabdominal preperitoneal (rTAPP) approach 2, 3, 4
- High-definition visualization and articulating instruments to refine the repair and lessen pain 3, 4
- Use of a structural mesh, such as a 4x6 inch polypropylene mesh, for reconstruction 3, 5
- Fixation of the mesh is not necessary, but fibrin sealant may be used routinely 3, 4
- Lower insufflation pressures, such as 8-12 mm Hg, may be used to reduce complications 3
Key Considerations for Robotic Inguinal Hernia Repair
Some key considerations for robotic inguinal hernia repair include:
- Proper training, including simulators and proctors, is necessary for surgeons performing robotic inguinal hernia repair 4
- Having the same operating room team and an interested first assistant at the OR table is very helpful 4
- The learning curve for robotic inguinal hernia repair is about 50 patients 4
- Postoperative narcotics are rarely needed, and urinary retention is the most common postoperative issue 4
- Use of peripheral alpha-blockers and straight catheterization in the OR at the conclusion of the surgery may help prevent urinary retention 4
Outcomes and Complications of Robotic Inguinal Hernia Repair
The outcomes and complications of robotic inguinal hernia repair include:
- Low recurrence rates and minimal postoperative pain 5, 4
- Uncommon complications, such as urinary retention and perforated sigmoid diverticulitis 3, 4
- Operating room time may be longer than standard laparoscopic herniorrhaphy, but decreases with experience 4
- Robotic inguinal hernia repair is safe and effective, with a low complication rate 2, 3, 4