Da Vinci Xi Right Inguinal Hernia Repair

The case

Walkthrough

What the surgeon does, and what to have in your hand before they ask.

1. 1

   Supine Positioning, Prep and Draping

   The patient is given general anesthesia and antibiotics per the hospital's protocol, then lies supine with both arms tucked at the sides. A Foley catheter is placed only if needed to drain a full bladder. Pad all bony prominences and secure padded shoulder braces, because the table will be tipped head-down. The robot is programmed per the maker's instructions for this case. For a right-sided repair the prep starts at the right groin and runs from just below the nipples to the mid-thigh on the right, well across the midline to the left, and down to the table on the right; a transabdominal repair needs a wide abdominal prep. Drape with folded towels and a laparotomy sheet, and cover the Xi arms and column with the sterile robot drapes.

   Next up: the first 8 mm da Vinci cannula with its obturator.

2. 2

   Insufflation and Port Placement

   An 8 mm cannula goes into the left upper quadrant first, and the abdomen is filled with CO2 through it. The second 8 mm cannula is placed in the midline below the umbilicus, about 15 cm above the pubic bone; this is the camera port. The third goes into the right upper quadrant. All three are the robot's own 8 mm cannulas, so no 10 or 12 mm port is needed for a standard repair.

   Next up: tilting the table and docking the patient cart.

3. 3

   Trendelenburg and Docking

   Anesthesia tips the table 10 to 20 degrees head-down so the bowel slides up out of the pelvis. The draped patient cart is brought in and docked, and its arms are attached to the three cannulas.

   Next up: the 30-degree endoscope for the midline port.

4. 4

   Loading the Camera and Instruments

   The 30-degree da Vinci endoscope goes through the midline port. A robotic grasper (such as the fenestrated bipolar forceps) and the monopolar curved scissors go through the two side ports. Plug the bipolar cord into the grasper and the monopolar cord into the scissors. The surgeon then moves to the console and runs the camera and both arms, so a bedside assistant may not be needed. Keep a laparoscopic suction ready on the field.

   Next up: the scissors and grasper for the peritoneal flap.

5. 5

   Landmarks and the Peritoneal Flap

   Any adhesions are freed first. The surgeon identifies the lateral umbilical ligament (it carries the inferior epigastric vessels) and the iliopubic tract running from the pubis to the anterior superior iliac spine, which separate a direct hernia from an indirect one. The area below the iliopubic tract and inside the femoral vein is checked for a femoral hernia. A peritoneal flap is cut about 4 to 5 cm above the right internal ring, from the medial umbilical ligament out toward the anterior superior iliac spine, then peeled downward toward the pubis and iliac vessels. It is freed from the cord, the hernia sac and any cord lipoma as it comes down.

   Next up: the same grasper and scissors to open the space and reduce the sac.

6. 6

   Clearing the Space and Reducing the Sac

   A pocket is opened between the peritoneum and the transversalis fascia, exposing the psoas muscle and the whole myopectineal orifice. The space is cleared inward past the pubis to Cooper's ligament and about 2 cm below the pubic symphysis, outward to the anterior superior iliac spine, about 2 cm above the conjoint tendon and down into the space between the bladder and pubis. The dissection stays on top of the transversalis fascia out to the side to protect the iliohypogastric nerve, and the genitofemoral nerve on the psoas is left alone. Around Cooper's ligament the surgeon watches for vessels crossing between the epigastric and obturator systems. The sac is separated from the internal ring with blunt and sharp dissection and very little cautery. A direct sac is pulled back with gentle traction. The peritoneum is freed past the point where the vas deferens and the testicular vessels split apart. In a woman, the round ligament may be divided at the internal ring.

   Next up: a camera check of the left groin.

7. 7

   Checking the Left Groin

   Through the same ports the surgeon can look at the left myopectineal orifice. If a second hernia is found and the patient consented to a bilateral repair, the left side gets its own separate flap and the same steps. Confirm before the case whether a left-sided repair is planned, so a second mesh is available.

   Next up: the mesh, sized and rolled so it fits through an 8 mm cannula.

8. 8

   Placing and Fixing the Mesh

   When the sac is reduced and bleeding is controlled, the mesh goes in. It is usually about 12 x 15 cm, self-gripping or standard polypropylene, and it must be a type that can pass through the 8 mm robotic cannula. The surgeon spreads it over the whole myopectineal orifice so the direct, indirect and femoral spaces are all covered. Many robotic surgeons sew the mesh in place with the robotic needle driver instead of using tacks, to save cost. Others fix it with absorbable or permanent tacks placed into firm structures (the pubis, Cooper's ligament, the aponeurotic arch and the lateral abdominal wall), or with cyanoacrylate glue or fibrin sealant, and self-gripping mesh may need no fixation. Have the laparoscopic tacker opened only if the surgeon asks for it.

   Next up: a running suture on the robotic needle driver for the flap.

9. 9

   Closing the Peritoneal Flap

   The flap is laid back over the mesh and closed with a running suture on the needle driver, which covers the mesh and helps keep the bowel from sticking to it.

   Next up: undocking, then the suture for the port sites.

10. 10

    Undocking, Letting the Gas Out and Closing

    The instruments come out, the arms are released from the cannulas and the cart is moved away. The cannulas are removed while the surgeon looks for bleeding, and the abdomen is emptied of gas while gentle pressure is put on the right groin to push out trapped gas and reduce swelling. All port sites are closed. Most patients go home the same day.

    Tips and Tricks

    Ask early which side is being repaired and whether the left will be explored or fixed, and have mesh that passes an 8 mm cannula. Hold the tacker, glue and extra mesh unopened until the surgeon decides on fixation. Keep a basic/minor tray, a conversion plan and the instrument release kit in the room, and review emergency undocking roles in the time-out.