Robotic-assisted Repair Research Articles

185 - Robotic-assisted repair surgery for recurrent complex colorectal vesical fistula: Technique of one stage surgery

185 - Robotic-assisted repair surgery for recurrent complex colorectal vesical fistula: Technique of one stage surgery

Robotic-Assisted Repair of a Left Lower Quadrant Spigelian-Type Hernia

Robotic-Assisted Repair of a Left Lower Quadrant Spigelian-Type Hernia

Optimizing outcomes in paraesophageal hernia repair: a novel critical view

BackgroundThe recurrence rate of paraesophageal hernia repair (PEHR) is high with reported rates of recurrence varying between 25 and 42%. We present a novel approach to PEHR that involves the visualization of a critical view to decrease recurrence rate. Our study aims to investigate the outcomes of PEHR following the implementation of a critical view.MethodsThis is a single-center retrospective study that examines operative outcomes in patients who underwent PEHR with a critical view in comparison to patients who underwent standard repair. The critical view is defined as full dissection of the posterior mediastinum with complete mobilization of the esophagus to the level of the inferior pulmonary vein, visualization of the left crus of the diaphragm as well as the left gastric artery while the distal esophagus is retracted to expose the spleen in the background. Bivariate chi-squared analysis and multivariable logistic and linear regressions were used for statistical analysis.ResultsA total of 297 patients underwent PEHR between 2015 and 2023, including 207 with critical view and 90 with standard repair which represents the historic control. Type III hernias were most common (48%) followed by type I (36%), type IV (13%), and type II (2.0%). Robotic-assisted repair was most common (65%), followed by laparoscopic (22%) and open repair (14%). Fundoplications performed included Dor (59%), Nissen (14%), Belsey (5%), and Toupet (2%). Patients who underwent PEHR with critical view had lower hernia recurrence rates compared to standard (9.7% vs 20%, P < .01) and lower reoperation rates (0.5% vs 10%, P < .001). There were no differences in postoperative complications on unadjusted bivariate analysis; however, adjusted outcomes revealed a lower odds of postoperative complications in patients with critical view (AOR .13, 95% CI .05–.31, P < .001).ConclusionWe present dissection of a novel critical view during repair of all types of paraesophageal hernia that results in reproducible, consistent, and durable postoperative outcomes, including a significant reduction in recurrence and reoperation.

The impact of overweight and obesity on the results of laparoscopic ventral hernia repair, including robot-assisted repair - a literature review

Obesity is the fifth leading cause of death worldwide. In turn, ventral hernias (including an inguinal hernias) are one of the most common cases in general surgery. Minimally invasive techniques (laparoscopic or robot-assisted procedures) are becoming more and more popular in ventral hernia treatment compared to open procedures. The aim of this study is to analyze the impact of body mass index (BMI) value on the efficacy and safety of laparoscopic ventral hernia repairs, including inguinal hernia repairs. Numerous studies evaluating this relationship are available. In most studies, There were also no statistically significant differences in the rate of intraoperative complications, the median operative time, the median length of hospital stay, the rate of postoperative pain, the surgical site infection, the rate of postoperative complications, the median time to recurrence, and the rate of early and late recurrences between groups with different BMI values. Moreover, studies proved that laparoscopic ventral hernia repair in obese patients is more effective compared to the open repair. The analysis revealed that high BMI values do not have a statistically significant impact on the outcomes of laparoscopic repair, including robot-assisted laparoscopic repair, in patients with ventral hernias. However, it should be noted that the analyzed studies often have limitations. For this reason, it is essential to conduct multicenter studies and perform long-term evaluations of patients.

Robotic-assisted repair of a large isthmocele

Robotic-assisted repair of a large isthmocele

Robot-assisted uretero-enteric reimplantation for uretero-enteric anastomotic strictures following robot-assisted radical cystectomy: Surgical approach and outcomes over two decades

ObjectiveWe described the technique and outcomes of robot-assisted repair of uretero-enteric strictures (UES) following robot-assisted radical cystectomy (RARC) and urinary diversion. MethodsRetrospective review of our RARC database from November 2005 to August 2023 at Roswell Park Comprehensive Cancer center was performed. Patients who developed UES and ultimately underwent robot-assisted uretero-enteric reimplantation (RUER) were identified. Kaplan–Meier method was used to compute the cumulative incidence recurrence rate of UES after RUER. A multivariable regression model was used to identify variables associated with UES recurrence. ResultsA total of 123 (15%) out of 808 RARC patients developed UES, of whom 52 underwent reimplantation (45 patients underwent RUER [n=55 cases] and seven patients underwent open uretero-enteric reimplantation). The median time from RARC to UES was 4.4 (interquartile range 3.0–7.0) months, and the median time between UES and RUER was 5.2 (interquartile range 3.2–8.9) months. The 3-year recurrence rate after RUER is about 29%. On multivariable analysis, longer hospital stay (hazard ratio 1.37, 95% confidence interval 1.16–1.61, p<0.01) was associated with recurrent UES after RUER. ConclusionRUER for UES after RARC is feasible with durable outcomes although a notable subset of patients experienced postoperative complications and UES recurrence.

Short-term outcomes after open versus robot-assisted repair of ventral hernias: a nationwide database study

PurposeThe robotic platform is widely implemented; however, evidence evaluating outcomes of robotic ventral hernia repair is still lacking. The aim of the study was to evaluate the short-term outcomes after open and robot-assisted repair of primary ventral and incisional hernias.MethodsNationwide register-based cohort study with data from the Danish Ventral Hernia Database and the National Danish Patients Registry was from January 1, 2017 to August 22, 2022. Robot-assisted ventral hernia repairs were propensity score matched 1:3 with open repairs according to the confounding variables defect size, Charlson comorbidity index score, and age. Logistic regression analyses were performed for factors associated with length of stay > 2 days, readmission, and reoperation within 90 days.ResultsA total of 528 and 1521 patients underwent robot-assisted and open repair, respectively. The mean length of hospital stay in days was 0.5 versus 2.1 for robot-assisted and open approach, respectively (P < 0.001) and open approach was correlated with risk of length of stay > 2 days (OR 23.25, CI 13.80–39.17, P < 0.001). The incidence of readmission within 90 days of discharge was significantly lower after robot-assisted repair compared to open approach (6.2% vs. 12.1%, P < 0.001). Open approach was independently associated with increased risk of readmission (OR 21.43, CI 13.28–39.17, P = 0.005, P < 0.001).ConclusionRobot-assisted ventral hernia repair is safe and feasible and associated with shorter length of stay and decreased risk of readmission compared with open ventral hernia repair.

Robotic-assisted repair of incisional hernia—early experiences of a university robotic hernia program and comparison with open and minimally invasive sublay technique (eMILOS)

PurposeWith robotic surgical devices, an innovative tool has stepped into the arena of minimally invasive hernia surgery. It combines the advantages of open (low recurrence rates and ability to perform complex procedure such as transverse abdominis release) and laparoscopic surgery (low rate of wound and mesh infections, less pain). However, a superiority to standard minimally invasive procedures has not yet been proven. We present our first experiences of robotic mesh repair of incisional hernias and a comparison of our results with open and minimally invasive sublay techniques.MethodsA retrospective analysis of all patients who underwent robotic-assisted mesh repair (RAHR) for incisional hernia between April and November 2022 (RAHR group) and patients who underwent open sublay (Sublay group) or eMILOS hernia repair (eMILOS group) between January 2018 and November 2022 was carried out. Patients in the RAHR group were matched 1:2 to patients in the Sublay group by propensity score matching. Patient demographics, preoperative hernia characteristics and cause of hernia, intraoperative variables, and postoperative outcomes were evaluated. Furthermore, a subgroup analysis of only midline hernia was performed.ResultsA total of 21 patients received robotic-assisted incisional hernia repair. Procedures performed included robotic retro-muscular hernia repair (r-RMHR, 76%), with transverse abdominis release in 56% of the cases. In one patient, r-RHMR was combined with robotic inguinal hernia repair. Two patients (10%) were operated with total extraperitoneal technique (eTEP). Robotic-assisted transabdominal preperitoneal hernia repair (r-TAPP) was performed in three patients (14%).Median (range) operating time in the RAHR group was significantly longer than in the sublay and eMILOS group (291 (122–311) vs. 109.5 (48–270) min vs. 123 (100–192) min, respectively, p < 0.001). The meshes applied in the RAHR group were significantly compared to the sublay (mean (SD) 529 ± 311 cm2 vs. 356 ± 231, p = 0.037), but without a difference compared to the eMILOS group (mean (SD) 596 ± 266 cm2). Median (range) length of hospital stay in the RAHR group was significantly shorter compared to the Sublay group (3 (2–7) vs. 5 (1–9) days, p = 0.032), but not significantly different to the eMILOS group. In short term follow-up, no hernia recurrence was observed in the RAHR and eMILOS group, with 9% in the Sublay group. The subgroup analysis of midline hernia revealed very similar results.ConclusionOur data show a promising outcome after robotic-assisted incisional hernia repair, but no superiority compared to the eMILOS technique. However, RAHR is a promising technique especially for complex hernia in patients with relevant risk factors, especially immunosuppression. Longer follow-up times are needed to accurately assess recurrence rates, and large prospective trials are needed to show superiority of robotic compared to standard open and minimally invasive hernia repair.

Two cases of robot-assisted repair of bronchial injury caused during robot-assisted lobectomy

Two cases of robot-assisted repair of bronchial injury caused during robot-assisted lobectomy

Robotic-Assisted Repair of Ureteroenteric Strictures after Cystectomy with Urinary Diversion: Technique Description and Outcomes from the ERUS Scientific Working Group.

Robotic-assisted repair of benign ureteroenteric anastomotic strictures (UAS) provides an alternative to the open approach. We aimed to report short-, medium-, and long-term outcomes for robotic repair of benign UAS, and to provide a detailed video demonstration of critical operative techniques in performing this procedure robotically. Between January 2013 and September 2022, 31 patients from 7 institutions who previously underwent radical cystectomy and subsequently developed UAS underwent robotic repair of UAS. Perioperative variables were prospectively collected, and postoperative outcomes were assessed. The surgery starts with a lysis of adhesions after previous surgery. Ureters are dissected, and the level of the stricture is identified. The ureter is then divided, and the stricture is resected. Finally, the ureter is spatulated and reimplanted with Nesbit technique after stenting with double-J stents. In cases where both ureters show strictures, Wallace technique for reimplantation can be applied. After robotic or open cystectomy, 31 patients had a total of 43 UAS at a median (IQR) follow-up of 21 (9-43) months. Median stricture length (cm) was 2.0 (1.0-3.25), operative duration (min) was 141 (121-232), estimated blood loss (mL) was 100 (50-150), and length of hospital stay (days) was five (3-9). One (3.2%) case was converted to open and one (3.2%) intraoperative complication occurred. Seven (22.6%) patients experienced postoperative complications, including four (12.9%) Clavien-Dindo grade 3 complications. No Clavien-Dindo grade 4 or 5 complications occurred. Stricture recurrence occurred in 2 (6.5%) patients. These results demonstrate that robotic repair of UAS is feasible and effective approach with outcomes in line with prior open series.

ThTP2.14 Robot-assisted repair of paraoesophageal hernia: a systematic review

Abstract Aim Laparoscopic repair is quoted as the standard of care for paraoesophageal herniae but limitations include the 2D image, requirement of a trained camera assistant and surgeon fatigue. Robotic-assisted (RA) repair promises improved 3D visualization and ergonomics. However, there is limited data on short and long-term outcomes from RA repair. We aimed to systematically review literature on RA repair of paraoesophageal herniae and post-operative outcomes. Methods A systematic on-line literature search of Embase and Medline identified 200 articles of which 13 relevant studies were selected, including 7 retrospective and 6 prospective studies. Selected articles were assessed by two reviewers to extract relevant demographic and outcome data. Results 1601 patients received RA repair of paraoesophageal herniae with a median age of 62 years and 72% were female. The majority had Hill type 3 paraoesophageal herniae (80.5%). Predominately elective operations (86.4%) they had a mean operative time of 169.7 minutes, used mesh in 44.0% and included a fundoplication in 78.2%. Only one required open conversion. Median length of stay was 2.45 days (1.3-4.5 days). 15.4% had reported complications (dysphagia (9.7%), pneumothorax (0.4%), pneumonia (0.3%) post-operative haemorrhage (0.3%) and thrombosis (0.4%)). There were no post-operative mortalities. Few symptomatic recurrences were reported and there was a 1.8% re-operation rate within this cohort. Conclusion RA paraoesophageal hernia repair offers similar outcomes to those published in recent literature for laparoscopic repair, with potential for improved surgeon ergonomics and visualisation. Carefully designed, prospective trials comparing laparoscopic and robotic repair are required to further delineate the optimal surgical approach.

V-009 Robot-Assisted Repair of a Traumatic Hernia After a Pelvic Fracture: Case Report and Literature Review

Abstract Aim Traumatic abdominal wall hernias (TAWH) are an uncommon clinical entity, accounting for less than 0.2% of all blunt trauma injuries. Management and operative technique are still a matter of debate and the role of the robotic surgical platform in traumatic hernias has not been reported on. We present a robot-assisted repair of a TAWH through a fracture of the left iliac wing. We aim to describe our operative approach and perform a review of the literature. Material and methods A 46-year-old male with a history of a high energetic trauma presented with a symptomatic swelling in the left lumbar region. Further imaging showed an important defect of the abdominal wall caused by a disruption of the iliac and gluteus muscles and non-union of a left iliac wing fracture. This caused a herniation of the descending colon. A robot-assisted transabdominal preperitoneal hernia repair (TAPP) with synthetic mesh was performed in elective setting. Results The postoperative course was uneventful. Discharge was possible at postoperative day one. There was no surgical site infection, seroma, or recurrence after a follow-up period of 6 months. Conclusions To our knowledge, we describe the first robot-assisted repair of a TAWH through a pelvic fracture. Our technique was safe and feasible. In difficult to reach areas of the abdomen, a robot-assisted repair might be a valid approach. Larger studies are needed to confirm our initial experience in traumatic abominal wall hernia surgery.

BJS-01 NATIONWIDE ANALYSIS OF SHORT-TERM OUTCOMES AFTER OPEN VS. ROBOT-ASSISTED REPAIR OF VENTRAL HERNIA

Abstract Background The aim was to evaluate short-term outcomes after robot-assisted and open repair of primary ventral and incisional hernia. Methods Nationwide register-based cohort study with data from the Danish Ventral Hernia Database and the National Danish Patients Registry from January 1, 2017 to August 22, 2022. Robot-assisted ventral hernia repairs were propensity score matched 1:3 with open repairs according to the confounding variables defect size, type of hernia, Charlson comorbidity index score, and age. Logistic regression analyses were performed for factors associated with length of stay &amp;gt; 2 days, readmission, and reoperation within 90 days. Results A total of 550 and 1,655 patients underwent robot-assisted and open repair, respectively. The mean length of hospital stay in days was 0.5 vs. 1.9 for robot-assisted and open approach, respectively, (P &amp;lt; 0.001) and open approach was correlated with risk of length of stay &amp;gt; 2 days (OR 4.69, CI 6.56–7.85, P &amp;lt; 0.001). The incidence of readmission and reoperation within 90 days of discharge was significantly lower after robot-assisted repair compared to open approach (7.0% vs. 15.6%, P &amp;lt; 0.001) and (2.0% vs. 4.4%, P = 0.013), respectively. Open approach was independently associated with increased risk of readmission and reoperation (OR 2.46, CI 1.73–3.51, P = 0.005) and (OR 2.30, CI 1.21–4.38, P = 0.011), respectively. Conclusion Robot-assisted ventral hernia repair is safe and feasible and associated with shorter length of stay and decreased risk of readmission and surgical reintervention compared with open ventral hernia repair.

Successful pregnancy outcome after robotic-assisted repair of isthmocele

Successful pregnancy outcome after robotic-assisted repair of isthmocele

Robot-assisted repair of primary uncomplicated inguinal hernia: comparisons to conventional laparoendoscopic repair

Abstract BACKGROUND AND METHOD: Robotic hernia surgery is progressing more and more, so that the robotic procedure is also used in the groin. We compared our patients who were operated on laparoscopically using the TEP technique with patients who were operated on robotically using the TAPP technique. RESULTS: The rTAPP can be safely performed without any problems and has many advantages, but the operating time is significantly longer than the laparoscopic TEPP. CONCLUSION: Inguinal hernia surgery can certainly be learned quickly and effectively as an introduction to robotics. It remains to be seen whether it will prevail in terms of surgical time and economics.

Robot-assisted repair of hiatal hernia: Advantages and disadvantages in comparison to conventional laparoscopic repair: A literature review

Abstract The laparoscopic fundoplication has proven to be the standard technique of antireflux surgery and hiatal hernia (HH) repair over the last decade. However, robot-assisted surgery is more and more implemented in daily practice. Several studies have proven the feasibility and safety of robot-assisted HH repair and antireflux surgery. Both approaches seem to be similar regarding perioperative and postoperative complications, length of hospital stay, postoperative symptoms, and quality of life, as well as objective assessment of gastric acid exposure. Nevertheless, high total costs as well as a considerably longer total operating time of robot-assisted surgery need to be considered. The role of robot-assisted surgery in complex cases is promising but needs to be evaluated. Eventually, the decision regarding the technique used should be based on the surgeon’s discretion and experience.

Robot-assisted repair of complicated inguinal hernia: Advantages in comparison with conventional repair

Abstract The adoption rate of robot-assisted surgery has skyrocketed in recent years, despite limited evidence, an unclear clinical benefit, and an increase in cost. The laparoscopic approach to inguinal hernia repair by either transabdominal or extraperitoneal approach has gradually gained traction owing to distinct advantages over traditional open repairs. Although robotic inguinal hernia repair has been established as a safe alternative to conventional laparoscopy, as of yet no superiority has been proven. We aim to give an overview of certain clinical situations, in which the robot might be advantageous. Specifically, we discuss inguinoscrotal hernia repair, inguinal hernia repair after prostatectomy, and mesh explantation. In our opinion, robotic systems are an invaluable tool in the case of mesh resection or recurrence after previous anterior and posterior repairs. With the increased expansion of the surgical tools and techniques to repair abdominal wall problems, a definitive and clear rule as to which cases should be handled robotically and which should not will be difficult and probably unattainable. We are very much proponents of a tailored approach, where every individual case deserves its surgical plan, bearing in mind all aspects of a patient, with the aim of the best surgical outcome.

Robot-assisted repair of incisional hernia of the abdominal wall: Which access is better—endoscopic totally extraperitoneal preperitoneal plasty (eTEP) or mini- or less-open sublay (e)(MILOS), some first considerations

Abstract Numerous metanalyses have shown that the retromuscular mesh placement is superior to other positions in terms of recurrence and complication rate. As a result, there has been a surge in novel minimally invasive retromuscular surgical techniques. We compared total extraperitoneal plasty (eTEP) and hybrid Mini/Less-open-Sublay [(e)MILOS] with respect to their adaptability to a surgical robotic system. Unfortunately, there is little to no literature regarding robotic adaptation of the (e)MILOS procedure, which made it rather difficult to juxtapose, but then again also implies that it is not commonly performed. As many benefits as the robot brings to endoscopic surgery, however, there is one major constraint when it comes to directionality. In eTEP dissection is performed in one direction and the trocars are positioned at the edge of the dissection field. The centripetal preparation of the (e)MILOS procedure is less suitable for the currently available systems and would naturally require multiple un- and re-dockings of the robot. Alternatively, the robot could only be used for a minor part of the operation. Looking at the published data concerning laparoendoscopic (e)MILOS and eTEP, there appears to be no significant difference in terms of major complications as well as reoperation and infection rates. However, a comparison to a robot-assisted eTEP cannot be done due to lack of publications. Judging from our own experience, we believe the eTEP technique to harness the advantages of the robot in addition to those of minimally invasive surgery more effectively. Within the last two decades, we have been experiencing a constant increment of endoscopic procedures in hernia surgery. This surge is nonetheless thanks to the availability of robotics in a continuously increasing number of hospitals in Europe and the United States. The combination of the advantages of minimally invasive surgery and robotic systems has been discussed and elaborated on many occasions and platforms. Hence, the goal of this analysis is to compare two broadly established minimally invasive (or less open) retromuscular methods in hernia repair surgery with regard to their adaptability to a surgical robot.

Robotic Redo Mitral Valve Replacement and Atrioventricular Groove Pseudoaneurysm Repair.

We report the use of robot-assisted right thoracotomy in the management of a patient who presented with acute-on-chronic congestive heart failure, associated with a contained atrioventricular dissection and 2 prior mitral valve replacements. Our patient had evidence of a contained rupture, as represented by preoperative cross-sectional imaging. The anatomic sequela from this was a ventricular pseudoaneurysm, which was likely survivable due to adhesions from prior operations buttressing the margins of the defect. Expansion of the pseudoaneurysm likely contributed to the dehiscence of the prosthesis. Our case illustrates an unprecedented resolution of a serious complication, managed effectively and efficiently by a robot-assisted procedure. With a successful outcome of totally endoscopic and robot-assisted repair, we demonstrate the versatility of minimally invasive techniques in addressing complicated anatomy as well as a surgical field scarred by multiple prior surgeries.

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.