By Karen Blum

Baltimore—Tips on using surgical robots efficiently for transabdominal preperitoneal repair of hernia and the application of robotics for acute care surgeons were presented at the 2019 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons.

Hernia Surgery: Setup and Technique

Because of the high cost of robotic systems, to maximize the value, it pays to use the robot only for selected hernia patients who will benefit most, and to do the procedure in the most efficient way possible, said Andrew T. Bates, MD, FACS, an assistant professor of surgery and the director of the Stony Brook Comprehensive Hernia Center at Stony Brook University Hospital, in New York.

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“Right now, the benefits [of robotic hernia repair] are very difficult for the literature to examine because they’re highly surgeon–patient dependent,” said Dr. Bates, “so one repair that might be really well suited for the robot may not be as suited for another patient.”

Although studies of cost-effectiveness lump everyone together under one giant umbrella, overall they are demonstrating that use of robotic systems results in longer operating times and higher procedural costs but also lower pain scores and shorter PACU stays, he said.

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Dr. Bates uses robotics for patients who are overweight or obese, or have large cord lipomas, scrotal hernias and large direct sacs. To minimize costs, he said, “simplicity is king.”

Having a consistent setup and technique will lead to faster OR and turnover times and prevent snafus if your regular team isn’t available. Employ fewer instruments to lower the procedural cost, and try to make your instruments do double duty so you don’t have to constantly switch them out, Dr. Bates advised. In addition, don’t be afraid of the anterior approach. “Going back into a previously operated posterior plane just because you want to use the robot is not a good use of the tool,” he said. Contraindications are similar to other posterior repairs, such as previous posterior repair, pelvic radiation, and previous pelvic trauma or infections.

For the procedure, position the patient on a supine, flexed bed. For the Trendelenburg position, use a very high-friction pad so the patient doesn’t slide with a robot docked to them. Protect the patient’s head and face, and consider a side dock, which Dr. Bates said allows him to get to both sides of the groin without any limitations in range of motion.

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Try to keep to three robotic instruments during the repair to save time and steps, Dr. Bates pointed out. He prefers a grasper like the ProGrasp (Intuitive Surgical) or Caudier, monopolar scissors and a needle driver. Consider Vicryl sutures (Johnson & Johnson) for peritoneal closure, and try to avoid a tacker with mesh fixation because it is just one more thing to open and an additional cost, he said. Make sure to get all the materials ready at the beginning of the case, before you dock the robot, so you don’t have to take anything out to reinsert a needle or mesh.

When starting your flap, Dr. Bates said, “getting into the proper plane is really key” for easier dissection and less risk for nerve injury or chronic groin pain, so use preperitoneal fat to your advantage. He prefers to start laterally, working medially. Gentle tension should be used, with a burn–push technique, and tunneling should be avoided.

For the hernia sac dissection, Dr. Bates said, follow the commandments of the nine-step critical myopectineal orifice plan. Use cautery judiciously, reducing all lipomas and eliminating all lead points for early recurrence. “I like to dissect down laterally and medially first, before really addressing the cord,” he said. “I think this really helps to zero in on the hernia sac and it exposes it from different sides, giving you more options on how to attack it,” Dr. Bates said. Surgeons can use the needle driver as a second grasper for hand-over-hand help, and use the underside of the peritoneum to stay in the right plane and know the location of the sac.

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When it comes to mesh placement, according to Dr. Bates, use suture when you can over a tacker. Dr. Bates said he likes to pre-roll self-adherent mesh and secure it with a suture, then position it before cutting the suture and unrolling it, to make it easy to work with. When closing the peritoneum, he said, “sew, sew, sew.” Try to maintain your cut edge, and avoid rolling the peritoneum.

Acute Care Surgery: Start Simple

Acute care surgeons also can take advantage of robotic systems in their practices, said Andrea M. Pakula, MD, MPH, FACS, a trauma, critical care and acute care surgeon, and minimally invasive/robotic surgeon, at Los Robles Medical Center in Thousand Oaks, Calif. Traditionally, acute care surgeons have used maximally invasive procedures for trauma, emergency and complex general surgery procedures, she said. Because of this, they may have limited exposure to minimally invasive procedures and use the techniques mainly for routine cases, such as appendectomy and gallbladder removal.

“If you’re an acute care surgeon wanting to expand your skill set and bring robotics into your toolbox, then your initial cases need to be simple,” Dr. Pakula said, such as inguinal hernia, small umbilical hernias or gallbladder removal. “You’re not going to jump into the most difficult of cases as you’re getting comfortable with the technology. It’s especially important to have a thoughtful progression of case complexity in order to ensure procedural success and patient safety.” As you go through your learning curve, you can apply the system to more complex cases.

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The robot has enabled many surgeons to expand their skill set with minimally invasive techniques especially in hernia repair, said Dr. Pakula. In her case, she used the robotic system first for intraperitoneal onlay mesh repair, then transabdominal preperitoneal repair, then totally extraperitoneal repair, and then transversus abdominis muscle release. The robotic approach now makes up the majority of Dr. Pakula’s practice.

“Many of these patients I wouldn’t have approached with traditional laparoscopy, and the robotic platform has allowed me to offer that skill set in both the elective and acute care setting to my patients,” Dr. Pakula said.


Dr. Pakula is a speaker and trainer for Bard Davol and Intuitive Surgical. Dr. Bates reported no relevant financial conflicts of interest.