Robotic-Assisted Laparoscopic (rTAPP) Bilateral Inguinal Hernia Repair

There are over 1 million hernia repairs performed annually in the US. Robotics is revolutionizing the adoption of minimally-invasive hernia repairs lately. For 20 years, in spite of the literature supporting the benefit of laparoscopic minimally-invasive repairs, only 25–30% of all hernias were performed laparoscopically. From 2015 to 2018, robotic laparoscopic hernia repairs have explosively grown from less than 2% to 20% of all hernia repairs performed in the US. Hernia repairs are among the most basic procedures for general surgeons, and there is substantial enthusiasm on the part of surgeons regarding the rapid changes in techniques as well as the best methods of teaching them. Surgical training programs may find it difficult to maintain training for their residents and fellows in the face of rapidly evolving technology. Therefore, we present the case of a 28-year-old male with bilateral inguinal hernias that were repaired using a robotic-assisted laparoscopic approach.

Inguinal hernias are among the most common surgical problems. Approximately 20 million hernia repairs are performed every year worldwide. Surgical repair of inguinal hernias is one of the oldest procedures in the history of medicine; it is not surprising, therefore, that herniorrhaphy has evolved substantially, particularly over the last 40 years.

The goals of hernia repair are prevention of incarceration with strangulation, reduction of acute and chronic pain, and rapid return to normal activity. The introduction of laparoscopic herniorrhaphy in the 1990s, as part of the general movement toward minimally-invasive surgery, provided several advantages for the treatment of inguinal hernias. These include smaller wounds, with subsequent lower incidence of wound infections and better cosmetic results. Patients in general complain less of postoperative discomfort and they enjoy more rapid recovery. An additional advantage of laparoscopy for this condition is the ability to treat several hernias during one approach.¹

The introduction of robotic-assisted laparoscopic surgery added further advantages of three-dimensional vision and added degrees of freedom in terms of range of motion.² Despite the many advantages of the robotic-assisted laparoscopic hernia repair, use of the technique is limited by lack of availability of equipment and a shortage of teaching materials for attending surgeons and surgeons-in-training. Therefore, we present the following case of a robotic-assisted laparoscopic bilateral hernia repair.

The patient is a 28-year-old male with bilateral inguinal hernias. The left-side hernia was somewhat larger than than that of the right, although both were relatively small. We elected to perform a robotic-assisted repair using the da Vinci device with three trocars placed straight across in a line. The first port was placed about 4–5 cm superior to the umbilicus in the midline.

Patients with inguinal hernias most commonly complain of a bulge in the groin, which may or may not be associated with pain. The focused physical exam consists of palpation of the inguinal canal with the patient standing. In a male patient, the examiner uses their gloved index finger to palpate the area of the external ring via the redundant skin from the scrotum. If an inguinal hernia is present the examiner will feel a bulge with the tip of their finger. The patient may be asked to perform a Valsalva maneuver. A second exam may be performed with the patient supine to determine reducibility.

Preoperative imaging is not required in the setting of a typical history and physical exam, and is reserved for complex and/or non-reducible cases.

Traditionally, it has been difficult to determine the true natural history of inguinal hernias because of the difficulty in identifying a sufficiently large cohort of patients who have elected not to have their hernias repaired. The general consensus is that inguinal hernias should be repaired to prevent intestinal strangulation.

Two randomized controlled trials in recent years have shed some light on the natural history of inguinal hernias.^3,4 In both studies, men with asymptomatic hernias were randomized to either watchful waiting or surgical repair. Both trials found that the rate of incarceration in the watchful waiting group was low (2.4–2.5%). Nevertheless, both trials demonstrated that men who present to their physician with complaints of a lower abdominal bulge are highly likely to present for surgery within a few years of the initial visit.

In females, the current recommendation is that all groin hernias should be repaired, as the incidence of femoral hernias is higher, and the risk of groin incarceration/strangulation is much higher than in men.⁵

For patients with primary unilateral inguinal hernias, the surgical options are open, whether anterior and/or posterior approaches, or endoscopic. The anterior Lichtenstein procedure is considered the gold standard for open approaches in the US. For endoscopic approaches, the particular type of procedure chosen (transabdominal preperitoneal or total extraperitoneal) is left to the discretion of the surgeon. Currently available data do not indicate superiority of open vs. laparoscopic herniorrhaphies in terms of outcomes.⁶

The primary rationale for repair of inguinal hernias is to prevent or treat intestinal strangulation. The secondary rational is to relieve pain associated with the hernia.

Absolute contraindications to robotic inguinal hernia repair include contamination of the abdominal cavity, inability of the patient to tolerate pneumoperitoneum or general anesthesia, and uncontrolled coagulopathy.

This was a robotic-assisted laparoscopic repair of bilateral inguinal hernias in a previously healthy 28-year-old male. A notable feature of the case was the not uncommon finding of lipomas of the cord (actually preperitoneal fat) intimately associated with the cord structures. These lipomas can often balloon up into the defect and become significant. We were easily able to remove the lipoma without risk of injuring the vas or gonadal vessels. On the left, the moderately-sized indirect inguinal hernia sac was tightly adherent and tenacious. The robotic-assisted laparoscopic technique permitted relatively straightforward dissection. Technical steps of the procedure are reviewed in the video in detail with particular attention to achieving the standardized critical view of the myopectineal orifice dissection and mesh placement as codified by Daes and Felix.⁷

Inguinal hernia repairs have been reported since antiquity. Nevertheless, the procedure remained largely unchanged, even with the introduction of asepsis and anesthesia, until the late 20^th century. For treatment of bilateral inguinal hernias, as in our patient, endoscopic approaches have proven to be as effective as traditional open approaches, with equivalent recurrence rates, better cost-effectiveness, and shorter operative times.⁸

Robotic-assisted laparoscopic surgery represents the latest technical advancement for the treatment of an ancient surgical problem. Widespread dissemination of robotic equipment combined with a better understanding of the anatomy afforded by enhanced three-dimensional visualization, along with the creation of innovative variations on the operation will likely improve outcomes in the near future.

• The da Vinci Xi system

Nothing to disclose.

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.