Intracorporeal Robot-Assisted Microsurgical Vasovasostomy for the Treatment of Bilateral Vasal Obstruction Occurring Following Bilateral Inguinal Hernia Repairs with Mesh Placement

Abstract

Various surgical approaches have been described to manage iatrogenic inguinal vasal obstruction, including open microscopic, laparoscopic and robot-assisted techniques. The open and laparoscopic approaches are often limited in cases of extensive inguinal obstruction or inadequate intra-abdominal vasal length. The robotic approach offers novel opportunities to the operating surgeon, including performing microsurgical anastomoses in traditionally challenging locations. To our knowledge we describe the first intracorporeal robot-assisted, microsurgical vasovasostomy for iatrogenic vasal obstruction not amenable to standard microscopic repair. Bilateral intracorporeal robot-assisted microsurgical vasovasostomy was performed. The proximal vasa were transected and obstruction of the distal segments was confirmed. After docking the robot the intracorporeal regions of the vasa were transected at the internal ring. The proximal vasal segments were passed intracorporeally and approximated with 5-zero polypropylene sutures. A standard 2-layer anastomosis was performed intracorporeally using 10-zero/9-zero sutures. Total operative time was 278 minutes. No intraoperative or postoperative complications were noted. Semen analysis 8 weeks after the procedure demonstrated a total volume of 5.4 cc, 8.4 × 10(6) sperm per ml, 45.4 × 10(6) total sperm and 16% motility, consistent with a successful result. To our knowledge this represents the first reported case of intracorporeal outpatient vasovasostomy. These results demonstrate the feasibility of the procedure and highlight unique aspects of the robotic approach, which may offer advantages over the traditional microscope in select cases.