Anesthesia Implications for Bilateral Inguinal Hernia Repair via Robot
For bilateral robotic inguinal hernia repair, general anesthesia is required due to the need for pneumoperitoneum and patient positioning, with careful attention to urinary retention prevention, which is the most common postoperative complication. 1
Anesthetic Requirements
General anesthesia is mandatory for robotic transabdominal preperitoneal (TAPP) inguinal hernia repair, as the procedure requires:
- Creation of pneumoperitoneum for adequate visualization 2, 1
- Steep Trendelenburg positioning to displace bowel from the operative field 1
- Extended operative times (mean 54-174 minutes for bilateral cases) 1, 2
This contrasts with open inguinal hernia repair, where local anesthesia can be used in emergency settings without bowel compromise 3.
Key Perioperative Considerations
Urinary Management - Critical Priority
Urinary retention is the most problematic postoperative occurrence following robotic inguinal hernia repair 1. To mitigate this risk:
- Obtain detailed preoperative urinary history 1
- Consider peripheral alpha-blockers prophylactically 1
- Perform straight catheterization in the OR at conclusion of surgery 1
- One patient in a 78-patient series required overnight admission specifically for urinary retention management 2
Operative Time Implications
Bilateral robotic repairs have longer anesthetic exposure compared to laparoscopic approaches:
- Mean operative time: 2.9 hours (range 2.0-4.0 hours for bilateral cases) 4
- Mean robotic dock time: 2.0 hours 4
- Operating room time: 25-140 minutes (average 54.36 minutes), decreasing with surgeon experience 1
Patient Selection and Risk Stratification
Robotic repair should be reserved for clinically stable patients with appropriate surgical risk profiles 5. Consider:
- ASA class (average 2.01 in successful series) 1
- BMI range 17.5-42.3 is feasible 4
- Age range 18-85 years has been safely managed 4, 1
Contraindications to Robotic Approach
Do not proceed with robotic repair if:
- Active bowel strangulation or suspected necrosis is present 3
- Patient cannot tolerate general anesthesia 3
- Bowel resection is anticipated 3
- Peritonitis is present 3
In these scenarios, open repair under local anesthesia is preferred for emergency cases without bowel gangrene 3.
Postoperative Recovery Advantages
Despite longer operative times, robotic repair offers anesthetic benefits:
- Same-day discharge achieved in 74-77% of patients 4, 2
- Mean length of stay: 8 hours 2
- Postoperative narcotic requirements are minimal (rarely more than 3 hydrocodone pills) 1
- Lower postoperative pain scores (VAS 2.9 vs 3.8 for laparoscopic) 6
- Lower chronic pain incidence (0% vs 20% for laparoscopic recurrent hernia repair) 6
Special Bilateral Hernia Considerations
For bilateral cases specifically:
- Caution is advised due to increased risk of transient urinary retention 5
- 45 of 78 patients (58%) in one series underwent bilateral repair successfully 2
- Single-port robotic bilateral repair is technically feasible but requires specialized training 7
Common Pitfalls to Avoid
- Inadequate urinary assessment preoperatively - This is the primary cause of unplanned admissions 1
- Proceeding with robotic approach in unstable patients - Emergency strangulated hernias require immediate open intervention 8, 9
- Underestimating operative time - Ensure adequate anesthetic planning for 2-4 hour procedures 4
- Ignoring bladder injury risk - One bladder injury occurred in 43 patients, discovered and repaired intraoperatively 4
Postoperative Monitoring Requirements
Monitor for:
- Urinary retention (most common complication) 1
- Seroma formation (11/43 patients in one series) 4
- Hematoma (3.9% incidence) 2
- Wound infection (rare: 1.3%) 2
No mesh fixation is necessary when using robotic technique, though fibrin sealant can be used routinely 1.