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Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 1-6

Robotic transabdominal preperitoneal repair of complex inguinal hernias

Good Samaritan Medical Center, Tufts University School of Medicine, Brockton, MA, USA

Date of Submission14-Aug-2020
Date of Acceptance07-Sep-2020
Date of Web Publication22-Feb-2021

Correspondence Address:
Dr. Omar Yusef Kudsi
1 Pearl Street, Brockton, MA 02301
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijawhs.ijawhs_36_20

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BACKGROUND: Complex inguinal hernia repairs (IHR) have been defined based on previous relative contraindications for their minimally invasive repair. In this study, we aim to describe outcomes after complex robotic IHR (rIHR) and the associated challenges.
MATERIALS AND METHODS: A retrospective analysis was performed of patients who underwent complex rIHR in an elective setting between 2013 and 2020. Patients included into the study were those with a recurrence after posterior IHR, history of prostatectomy, large scrotal hernia, or irreducible hernia after anesthesia induction (incarcerated). Any patients with concomitant procedures or emergent repairs were excluded. Complications were assessed with the Clavien-Dindo (CD) and Comprehensive Complication Index (CCI®) scoring systems.
RESULTS: A total of 88 patients were identified. Accounting for bilateral IHRs, the total number of complex rIHRs was 110. Although there were no conversions to an open approach, one patient required a hybrid procedure. The average length of stay (LOS) and follow-up period were 0.2 days and 33 months, respectively. A total of four major complications (CD-Grade III/IV) were observed. These included three seromas requiring drainage, one of which necessitated readmission, and 1 postoperative intensive care unit admission. No chronic pain or recurrence was observed. The CCI® scores were ranged between 0 and 42.4. In a univariate analysis, no statistically significant variable was found between patients with and without postoperative complications.
CONCLUSION: Complex rIHR may be performed with minimal LOS, complications, and adverse long-term sequelae. A patient-tailored approach and adequate surgical training and knowledge are essential to attempt these procedures.

Keywords: Complex inguinal hernia, groin hernia, robotics, transabdominal preperitoneal

How to cite this article:
Kudsi OY, Bou-Ayash N, Gokcal F. Robotic transabdominal preperitoneal repair of complex inguinal hernias. Int J Abdom Wall Hernia Surg 2021;4:1-6

How to cite this URL:
Kudsi OY, Bou-Ayash N, Gokcal F. Robotic transabdominal preperitoneal repair of complex inguinal hernias. Int J Abdom Wall Hernia Surg [serial online] 2021 [cited 2021 Sep 17];4:1-6. Available from: http://www.herniasurgeryjournal.org/text.asp?2021/4/1/1/309979

  Introduction Top

It is estimated that 27% of men and 3% of women will experience an inguinal hernia throughout their lifetime, and around 20 million inguinal hernia repairs (IHRs) are performed each year globally. These highly prevalent hernias can have a wide range of etiologies and complicated presentations, and so, optimizing their surgical management is essential for improving patient outcomes.

An open (Lichtenstein) IHR has been the predominant surgical approach to these hernias. Laparoscopic totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) were also described and were shown to be advantageous to open repair in terms of overall morbidity.[1] Another minimally invasive approach is robotic IHR (rIHR), which has also been validated as a safe and feasible option in recent studies.[2] However, several factors have been considered as relative contraindications for minimally invasive repair, including previous posterior IHRs and pelvic surgery, scrotal hernias, and incarcerated hernias.[3],[4],[5] These complex hernias are often associated with increased operative times and risk of complications, but are also amenable to minimally invasive repair given adequate surgical knowledge and training.[6] In this study, we aim to describe the postoperative outcomes after complex rIHR.

  Materials and Methods Top

The data for this study were obtained from a prospectively collected database of cases performed between February 2013 and May 2020. From this case series, patients who underwent complex RIHR were identified based on the following: (1) recurrent hernias after previous posterior IHR, (2) patients with a history of prostatectomy, (3) irreducible hernias which remain incarcerated after induction of anesthesia, and (4) large scrotal hernias (>3 cm). Emergent hernia repairs and concomitant procedures were excluded. Unless contraindicated due to septic shock or severe cardiopulmonary disease, the surgeon's preferred approach for these hernias is rIHR. The variables included patient characteristics (age, sex, body mass index, comorbidities, and the American Society Anesthesiology score), hernia characteristics (etiology, side, and hernia contents), operative variables (the type of mesh, mesh dimensions, console and skin-to-skin times, estimated blood loss in ml, intraoperative complications, and conversion to open or laparoscopic approach), and postoperative variables (postoperative pain scores, the hospital length of stay [LOS], emergency readmission within 30-day after discharge, and complications).

Hernias were classified according to the European Hernia Society classification.[7] Postoperative pain scores were documented by an anesthesiologist using a 0–10 numeric rating scale system (0: no pain, 10: the worst pain). The pain score was recorded just before the patient left the postanesthesia care unit (PACU). The total amount of narcotic-analgesic received while in the PACU was also calculated. The LOS, in days, was defined as the difference in time between the date of the operation and the date of hospital discharge.

Postoperative complications were reviewed as documented in the surgeon's follow-up visit notes, as well as the medical records and clinical charts of the patients. All complications were categorized according to the Clavien-Dindo (CD) classification system.[8] The Comprehensive Complication Index (CCI®, University of Zurich, Zurich, Switzerland) was used to assess the morbidity.[9]

Surgical technique

The patient was placed in the supine position, and a Foley catheter was inserted. Following appropriate preparation, a Veress needle was inserted into the left upper quadrant to insufflate the abdomen, and a total of three trocars were inserted 8 cm apart and 4 cm above the level of the umbilicus and off-midline. The patient-side cart of the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, CA) was docked. Each procedure involves an average of three instruments, including a 0° scope. After docking, the inguinal hernia is identified, and peritoneal dissection is initiated 8–10 cm above the internal inguinal ring, starting at the median umbilical fold and proceeding laterally toward the anterior superior iliac spine. The dissection was extended inferiorly toward the deep inguinal ring, laterally toward the psoas muscle, and medially at least 2 cm between Cooper's ligament and the bladder to allow adequate mesh overlap in the space of Retzius. Inferior epigastric vessels were preserved, and cord structures were separated and the hernia contents were then reduced [Figure 1]. The hernia sac was carefully dissected from its attachments to avoid injury to structures in the triangle of doom. If present, lipomas were either reduced or excised. The recommendations of the International Hernia Collaboration's critical view of the myopectineal orifice (MPO) were followed.[10] After evaluation of the MPO for any hidden hernias and visualization of all anatomical elements, a minimum mesh size of 15 cm × 10 cm was introduced to cover the MPO. The peritoneal flap was then closed using absorbable barbed suture. Any fascial incisions larger than 10 mm, if present, as well as skin incisions, were closed using absorbable sutures after the administration of local anesthetic at the trocar sites.
Figure 1: (a) Recurrent hernia repair after previous posterior repair, (b) hernia repair after open prostatectomy, (c) incarcerated hernia repair, (d) scrotal hernia repair

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Statistical analysis

Data were collected and managed using the Research Electronic Data Capture (REDCap) Tool.[11] All statistical analyses were performed using the IBM SPSS Statistics for Windows, version 22 (IBM Corp., Armonk, N.Y., USA). Continuous variables were determined as either normally or nonnormally distributed by using either Kolmogorov–Smirnov or Shapiro-Wilk tests. Categorical variables were presented in terms of frequency (n [%]), whereas continuous variables were reported as the mean ± the standard deviation for normal distributions or the median with interquartile range (IQR) for nonnormal distributions. Univariate analyses were also performed, comparing all variables and the presence of postoperative complications. Categorical variables were analyzed using the Pearson Chi-square or Fisher's exact tests. Continuous variables were analyzed using the two-tailed Student's t-test (for normal distributions) or Mann–Whitney U-test (for nonnormal distributions). P < 0.05 was considered statistically significant.

  Results Top

Among the initial cohort of 616 patients, a total of 88 patients who underwent rIHR due to complex hernias were included. Patient demographics are presented in [Table 1]. Scrotal hernia and irreducible hernia were the most common indications for complex rIHR. Considering bilateral hernias, a total of 110 hernias were repaired. Hernia characteristics are summarized in [Table 2].
Table 1: Patient demographics

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Table 2: Hernia characteristics

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In 6 (6.8%) patients with a direct hernia, the imbrication of the hernia sac was performed. The most common mesh size and the material was a 16 cm × 12 cm ProGrip™ (Medtronic, Minneapolis, MN, USA) mesh, respectively. In one patient (1.1%), intraoperative bleeding occurred, and a suction drain was placed. A serosal intestinal tear occurred in one patient (1.1%) during peritoneal closure and was sutured. In one patient (1.1%) with a bilateral giant scrotal hernia (>30 cm scrotal diameter), the operation was completed with a combination of robotic and open approaches (hybrid). Operative variables are presented in [Table 3].
Table 3: Operative variables

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The median (IQR) pain score was 3 (2–4). During the PACU recovery period, 22.7% of patients did not require any pain medication. The median (IQR) morphine milligram equivalent was 7.5 (2.5–11.7). The majority of the patients were discharged on the same day of operation (90.9%). The mean hospital LOS was 0.2 days (minimum–maximum: 0–10). One (1.1%) patient was readmitted to the hospital within 30-days postoperatively due to a seroma, which required drainage.

A total of 15 (17%) patients were noted as lost-to-follow-up. Postoperative complications are presented in [Table 4] for 73 patients. The majority of postoperative complications were Grade-1, according to the CD classification. One patient required overnight intensive care unit follow-up for hemodynamic support (CD Grade-4a). In three (4.1%) patients with a postoperative seroma, a procedural intervention was needed (CD Grade-3a). Three (4.1%) patients experienced pain between 6 weeks and 3 months postoperatively. No patients complained of chronic groin pain, and there were no hernia recurrences within the mean postoperative follow-up period of 33 (minimum–maximum = 1.6–68.8) months.
Table 4: Postoperative complications

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No variables were significantly different between patients with and without postoperative complications, as shown in [Table 5].
Table 5: Univariate analyses for postoperative complications

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  Discussion Top

Previous violation of pelvic preperitoneal spaces has been considered by some surgeons to be a relative contraindication to minimally invasive surgery (MIS) for inguinal hernias since the preperitoneal/transversalis space is more likely to have been obliterated or made inaccessible due to associated scarring.[11] Therefore, in the event of a recurrence of posterior hernia repair, anterior repair techniques have been considered as safe surgical alternatives. On the other hand, some results have encouraged surgeons to utilize a repeated posterior approach.[12],[13],[14] Knook et al.[12] evaluated the results of 34 patients who underwent laparoscopic TAPP repair due to recurrence following endoscopic IHR. The mean operative time was 69 min, and there were no conversions to the anterior approach. After a mean follow-up of 35 months, no recurrences had been diagnosed. Van den Heuvel and Dwars[13] reviewed a total of 2,594 laparoscopic TAPP-IHRs. Of these, 53 repairs were attempted for recurrent hernias after a previous posterior repair. Two procedures were converted to an open technique. In a mean follow-up of 70 months, there were no severe postoperative events, and no recurrences were observed. In this study, the average operating time (skin-to-skin) was 103 min for the subgroup patients with a history of prior posterior IHR. Neither intraoperative complications nor open conversions was observed in this subgroup.

Much like posterior IHRs, radical prostatectomies involve the same anatomical plane and potential consequences for future repairs. Claus et al.[15] reported the outcomes of a prospective study to evaluate the feasibility and surgical outcomes of laparoscopic TAPP-IHR in patients who had undergone a previous radical prostatectomy. A total of 20 consecutive patients were identified, and there were no conversions to an open approach. Wauschkuhn et al.[6] compared surgical outcomes after laparoscopic TAPP between patients with primary hernias and patients with previous radical prostatectomies. They concluded that laparoscopic TAPP after radical prostatectomy could be performed efficiently and safely by skilled laparoscopic surgeons. Similarly, Dulucq et al.[16] revealed that laparoscopic TEP-IHR in patients after previous lower abdominal surgery or radical prostatectomy had comparable results to those without a history of prior surgery. In their study, two out of ten patients with a history of prostatectomy were converted to TAPP due to surgical difficulties, whereas none of the 16 patients with a history of another low abdominal surgery were converted. In our study, we did not include patients who had a history of lower abdominal surgery, apart from prostatectomies, since their prior operations might not have involved the retropubic space. Consequently, only three patients who had a history of open prostatectomy were included, with an average operative time of 68 min and no open conversions.

With regards to incarcerated hernias, a prospective study conducted by Leibl et al.[17] concluded that laparoscopic TAPP (IHR) represents an efficient therapeutic option for the treatment of both chronically and acutely incarcerated inguinal hernias. L-TAPP repair was performed for 158 chronically incarcerated hernias and 36 acute incarcerations. None of these procedures necessitated the conversion to an alternative surgical approach and the mean operative time was 55 min. Six patients with chronically incarcerated hernias in the L-TAPP group experienced postoperative complications. There were 37 patients in the current study's incarcerated hernia subgroup. The median operative time was 90 min, and postoperative complications were seen in seven patients.

Similarly, scrotal hernias may present challenges in terms of a difficult reduction and increased risk of intraoperative injury. In a study conducted by Siow et al.,[18] a total of 20 male patients with an incarcerated scrotal hernia underwent laparoscopic TAPP repair with a modified scrotal incision. The mean operative time was 143.7 min (range: 75–240). Surgical site or mesh infection was not observed in any of the cases. Likewise, no recurrence was encountered within the mean follow-up period of 22 months. Authors concluded that using the above modification, they were able to perform laparoscopic repair of large incarcerated scrotal hernias, which previously would have otherwise been treated with an open procedure. In another study, robotic TAPP scrotal hernia repair was successful in 14 patients with an average case duration of 100 min (78–140 min) for unilateral hernias and 208 min (166–238 min) for bilateral hernias.[19] Three patients developed postoperative seromas and there were no recurrences. The authors concluded that scrotal hernias could be safely repaired using robotic-assisted TAPP methods with low morbidity and favorable patient-reported outcomes. In the current study, 47 patients underwent scrotal hernia repair. 20/47 patients had an incarcerated scrotal hernia. The mean operative time was 78 min (range: 31–210). A hybrid procedure was performed in one patient whose hernia could not be reduced due to a large hernia sac of >30 cm diameter. A total of 5 patients experienced postoperative complications.

Depending on the etiology of the complex hernia at hand, specific technical considerations may arise. For patients with a previous posterior IHR or prostatectomy, navigating through dense scar tissue may be challenging. Previously placed mesh can often be adhered to the posterior flap, in which case, attempting mesh excision may create large holes which are difficult to close as well as compromise the quality of the posterior layer and increase risk of complications. This is also the case for mesh adhered to key vessels and cord structures. Leaving the mesh integrated and limiting excision to only curled or folded portions may help reduced this risk. Moreover, it is prudent to incise the peritoneum cephalad and proceed to create a large flap. This offers more tissue redundancy to allow for peritoneal tear closure and also offers ample space for mesh placement. Nevertheless, surgeons should be prepared to encounter intraoperative complications and inadvertent injuries. A common injury is to the bladder, which may be plastered to the symphysis pubis and difficult to identify. The risk of injury may be minimized by using a three-way foley catheter and Indocyanine Green or Methylene blue for proper visualization. Moreover, careful dissection of cord structures with lateral dissection and sparing using of bipolar energy devices may prevent nerve injury and its related complications. Similarly, these same principles may help avoid testicular devascularization in cases of scrotal hernias. In this study cohort, complete reduction of the hernia sac was favored with incarcerated hernias. An en-masse reduction technique was sometimes used, whereby external pressure and gentle traction facilitated reduction of these hernias. Regardless of the type of hernia repair, adequate MIS training, as well as knowledge of anatomy and trouble-shooting, are crucial factors to the success of these complex procedures.

Limitations of this study include its retrospective design and inherent selective bias. Moreover, no variables were found to be associated with postoperative complications, making it difficult to isolate the impact of any single hernia etiology on the surgical outcomes. This is especially the case with the prostatectomy subgroup, as it includes only three patients. The results of this study are also highly dependent on the surgeon's training and knowledge, which cannot be accounted for. Therefore, this study aims to describe the technical considerations and surgical outcomes after complex rIHR from a single surgeon's experience. The results of this study may be used to guide other MIS-trained surgeons who wish to attempt these procedures. Surgeons should always take into consideration their training and comfort with a procedure as well as patient and hernia characteristics before committing to one surgical approach.

  Conclusion Top

The absence of conversions, short LOS, and low rate of major complications support the feasibility of rIHR for patients with complex inguinal hernias. A patient-tailored approach and adequate surgical knowledge are key factors in the success of these procedures. Long-term multicenter studies are needed for result generalizability.

Ethical approval

This study was approved by the local ethical committee (IRB#:HW202, 03/2019, St. Elizabeth's Medical Center).

Consent for publication

Written informed consent for the publication was obtained from all study participants. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Financial support and sponsorship

Drs. Bou-Ayash and Gokcal have no conflicts of interest or financial ties to disclose. Dr. Kudsi has received a teaching course and/or consultancy fees from Intuitive Surgical and W.L. Gore outside the submitted work.

Conflicts of interest

There are no conflicts of interest.

  References Top

Köckerling F, Bittner R, Kofler M, Mayer F, Adolf D, Kuthe A, et al. Lichtenstein versus total extraperitoneal patch plasty versus transabdominal patch plasty technique for primary unilateral inguinal hernia repair: A registry-based, propensity score-matched comparison of 57,906 patients. Ann Surg 2019;269:351-7.  Back to cited text no. 1
Escobar Dominguez JE, Ramos MG, Seetharamaiah R, Donkor C, Rabaza J, Gonzalez A. Feasibility of robotic inguinal hernia repair, a single-institution experience. Surg Endosc 2016;30:4042-8.  Back to cited text no. 2
Prassas D, Rolfs TM, Knoefel WT, Krieg A. Meta-analysis of totally extraperitoneal inguinal hernia repair in patients with previous lower abdominal surgery. Br J Surg 2019;106:817-23.  Back to cited text no. 3
Deeba S, Purkayastha S, Paraskevas P, Athanasiou T, Darzi A, Zacharakis E. Laparoscopic approach to incarcerated and strangulated inguinal hernias. JSLS 2009;13:327-31.  Back to cited text no. 4
Matthews RD, Anthony T, Kim LT, Wang J, Fitzgibbons RJ Jr., Giobbie-Hurder A, et al. Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: A report from the VA Cooperative Hernia Study Group. Am J Surg 2007;194:611-7.  Back to cited text no. 5
Wauschkuhn CA, Schwarz J, Bittner R. Laparoscopic transperitoneal inguinal hernia repair (TAPP) after radical prostatectomy: Is it safe? Results of prospectively collected data of more than 200 cases. Surg Endosc 2009;23:973-7.  Back to cited text no. 6
Miserez M, Alexandre JH, Campanelli G, Corcione F, Cuccurullo D, Pascual MH, et al. The European hernia society groin hernia classification: Simple and easy to remember. Hernia 2007;11:113-6.  Back to cited text no. 7
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205-13.  Back to cited text no. 8
Slankamenac K, Graf R, Barkun J, Puhan MA, Clavien PA. The comprehensive complication index: A novel continuous scale to measure surgical morbidity. Ann Surg 2013;258:1-7.  Back to cited text no. 9
Daes J, Felix E. Critical view of the myopectineal orifice. Ann Surg 2017;266:e1-2.  Back to cited text no. 10
Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42(2):377-81.  Back to cited text no. 11
Knook MT, Weidema WF, Stassen LP, van Steensel CJ. Laparoscopic repair of recurrent inguinal hernias after endoscopic herniorrhaphy. Surg Endosc 1999;13:1145-7.  Back to cited text no. 12
van den Heuvel B, Dwars BJ. Repeated laparoscopic treatment of recurrent inguinal hernias after previous posterior repair. Surg Endosc 2013;27:795-800.  Back to cited text no. 13
Ertem M, Ozben V, Gok H, Ozveri E. Relaparoscopic treatment of recurrences after previous laparoscopic inguinal hernia repair. Minim Invasive Surg 2013;2013:260131.  Back to cited text no. 14
Claus CM, Coelho JC, Campos AC, Cury Filho AM, Loureiro MP, Dimbarre D, et al. Laparoscopic inguinal hernioplasty after radical prostatectomy: Is it safe? Prospective clinical trial. Hernia 2014;18:255-9.  Back to cited text no. 15
Dulucq JL, Wintringer P, Mahajna A. Totally extraperitoneal (TEP) hernia repair after radical prostatectomy or previous lower abdominal surgery: Is it safe? A prospective study. Surg Endosc 2006;20:473-6.  Back to cited text no. 16
Leibl BJ, Schmedt CG, Kraft K, Kraft B, Bittner R. Laparoscopic transperitoneal hernia repair of incarcerated hernias: Is it feasible? Results of a prospective study. Surg Endosc 2001;15:1179-83.  Back to cited text no. 17
Siow SL, Mahendran HA, Hardin M, Chea CH, Nik Azim NA. Laparoscopic transabdominal approach and its modified technique for incarcerated scrotal hernias. Asian J Surg 2013;36:64-8.  Back to cited text no. 18
Yheulon CG, Maxwell DW, Balla FM, Patel AD, Lin E, Stetler JL, et al. Robotic-assisted Laparoscopic Repair of Scrotal Inguinal Hernias. Surg Laparosc Endosc Percutan Tech 2018;28:188-92.  Back to cited text no. 19


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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