Robotic-assisted Inguinal Hernia Repair Research Articles

An Uncommon Cause of Testicular Infarct: A Case Report and Review of the Literature of Testicular Infarcts From Laparoscopic Inguinal Hernia Repair

BackgroundTesticular ischemia requires timely diagnosis and definitive management to avoid serious consequences such as orchiectomy. It is almost always caused by testicular torsion; however, there are other causes to be aware of. Case ReportA 32-year-old man developed testicular ischemia following a laparoscopic robotic-assisted inguinal hernia repair with preperitoneal mesh. The ischemia progressed to a fully infarcted testicle with no evidence of torsion on subsequent surgical exploration. He ultimately did require an orchiectomy. Why should an Emergency Physician be aware of this?While extremely rare, testicular ischemia or infarct must be considered in patients presenting with testicular pain shortly after inguinal hernia repair. Emergent surgical evaluation and loosening of the hernia mesh may be required to salvage the testicle.

What influences general surgery residents' prospective entrustment and operative time in robotic inguinal hernia repairs.

Teaching residents robotic-assisted inguinal hernia repair (RIHR) is an increasingly common extension of contemporary surgical training. This study sought to investigate what variables would influence operative time (OT) and resident prospective entrustment in RIHR cases. We prospectively collected 68 resident RIHR operative performance evaluations with a validated instrument. Outpatient RIHR cases performed by 11 general surgery residents during 2020-2022 were included. The overall OT of matched cases was extracted from hospital billing; matched procedural step-specific OT was obtained from Intuitive Data Recorder (IDR). Statistical analysis was performed using Pearson correlation and one-way ANOVA. The evaluation instrument reliably assessed residents' RIHR performance (Cronbach's α = 0.93); residents' prospective entrustment strongly correlated with overall guidance provided by attending surgeon (r = 0.86, p < 0.0001) and operative plan and judgment (r = 0.85, p < 0.0001). The overall OT was significantly associated with resident's team management (r = - 0.35, p = 0.011). Procedural step-specific OT was significantly associated with residents' step-specific skill (r = - 0.32, p = 0.014). On average, RIHR cases with the highest level of prospective entrustment (Resident can teach junior) showed the shortest step-specific OT. Entrustment level 3 (Reactive guidance needed) was the turning point of all four RIHR procedural step-specific OT. Our findings suggest that in RIHR, attending guidance, resident operative plan and judgment, and resident technical skill contribute to resident prospective entrustment; resident team management, technical skill, and attending guidance influence operative time, which in turn impacts attendings' determination of resident prospective entrustment. Future studies with a larger sample size are needed to further validate the findings.

Persistent bilateral pneumothorax after robotic-assisted inguinal hernia repair: possible relevance to recent esophageal cancer surgery — a case report

BackgroundPostoperative pneumothorax is a well-known but relatively rare complication after laparoscopic surgery. There has been no report describing pneumothorax that persisted for a week or more after laparoscopic surgery. Herein, we report a case of bilateral pneumothorax after laparoscopic surgery, which appears to have occurred by a different mechanism than previously described.Case presentationA 65-year-old male, with a past history of esophagectomy and retrosternal gastric tube reconstruction 4 months earlier, underwent a robotic-assisted inguinal hernia repair. Postoperative chest x-rays revealed the development of bilateral pneumothorax, which became worse on postoperative day (POD) 1 and took more than 9 days to resolve spontaneously. We assumed that intra-abdominal gas replaced by the air after pneumoperitoneum might have migrated into thoracic cavities through an opened esophageal hiatus or along the retrosternal route.ConclusionsLaparoscopic surgery after radical esophagectomy may be associated with an increased risk of postoperative pneumothorax.

Robotic-assisted inguinal hernia repair: A historical review

Inguinal hernia repair is one of the most common procedures performed in general surgery. Approximately 20 million hernia surgeries are performed every year worldwide. Conventionally, hernial repair is carried out with the open Lichtenstein technique; however, laparoscopic and robotic inguinal hernia repairs have been developed as a minimally invasive alternative to the classic Lichtenstein repair. The prosthetic mesh can be placed by totally extraperitoneal and transabdominal pre-peritoneal approaches. Choosing the best technique for repairing an inguinal hernia is a challenge because the available data are contradictory. However, a growing number of studies have claimed that robotic-assisted hernia repair is not only feasible and safe, but it is associated with outcomes that are comparable to those obtained with laparoscopy and open surgery, including shorter hospital stay, and fewer complications. The aim of the review article is to provide an overview of the current practice of inguinal hernia repair, with a focus on the advances in robotic-assisted inguinal hernia repair, as well as the advantages and disadvantages of this surgical procedure compared to the laparoscopic technique in view of the current reports in the literature. Keywords: Inguinal hernia, Laparoscopic inguinal hernia repair, Robotic-assisted inguinal hernia repair, Lichtenstein technique, Mesh, Transabdominal Pre-peritoneal approach, Totally extraperitoneal approach.

Robotic Inguinal Hernia Repair After Prostatectomy: How to Navigate Safely.

In recent decades, minimally invasive approaches have found their place in treating a specific subset of patients with inguinal hernias, predominantly those with recurrent or bilateral disease. Classically, prior history of urologic pelvic operations, such as prostatectomy, has been listed as relative contraindication for minimally invasive inguinal hernia repair. As the adoption of the robotics platform continues to grow, we aim to outline a feasible robotic-assisted inguinal hernia repair technique in patients with previous prostatectomies. We report the outcomes of 15 patients who underwent repair at 2 institutions. This is a retrospective case series of 15 patients who underwent robotic transabdominal preperitoneal approach repair of their inguinal hernias after prostatectomy. Demographics, intraoperative variables, and outcomes of our cases are described. Fifteen patients were included in our cohort. All patients had a history of prostatectomy (7 open, 2 laparoscopic, and 6 robotic) due to prostate cancer. Median age was 70 years old (range: 60 to 89 y), with a median body mass index of 26.3 kg/m2 (range: 20.5 to 37.4 kg/m2). Hernia defects were bilateral in 6 patients and unilateral in the remaining 9 (right; 6, left; 3). The shortest interval between prostatectomy and subsequent hernia repair was 4 months (range: 4 to 216 mo). The median operative time was 139 min (range: 91 to 281 min). All defects were repaired using a polypropylene mesh except in 1 case, where a coated monofilament polyester mesh was used after having a large peritoneal defect to close, preventing future adhesions to the bowel. Mesh sizes used were large (16×11 cm), extra-large (17×12 cm) for anatomic mesh, and 20×15 cm for the monofilament polyester mesh. The mesh was fixed in 14 of 15 cases. Fixation was accomplished with absorbable suture (n=13), barbed suture (n=1), and fibrin sealant (n=1). Peritoneal closure was always performed using a continuous running v-loc suture. There were no documented major intraoperative complications, no 30-day readmission, or recurrences recorded within the follow-up period. Postoperatively, only 2 seromas and 1 hematoma were documented during the follow-up period. Robotic inguinal hernia repairs in patients with previous prostatectomy is safe and feasible in most patients. Larger patient series are needed to confirm these findings.

A cost analysis of two- versus three-instrument robotic-assisted inguinal hernia repair with mesh: time is money.

Equipment expenses and operating times can lead to higher costs with robotic surgery. We compared the cost-effectiveness of 2- vs. 3-instrument (2i vs. 3i) approach to robotic transabdominal preperitoneal inguinal hernia repair. We conducted a retrospective study of 172 patients, with 86 patients in each group. Procedure cost, operative time, morbidity, length of stay, readmission rate, and hernia recurrence at 90days were compared. Statistical significance was assigned to p < 0.05. No significant differences in preoperative variables nor in postoperative outcomes were identified. Mean operative time was 6min longer in the 2i group and this approach cost $300 less. The 2i approach was cost-effective for operating room (OR) costs of less than $50 per minute. Surgeon efficiency and OR dollar-per-minute value influence the potential for cost savings with fewer instruments in robotic herniorrhaphy. There is no difference in outcomes when fewer instruments are used.

Feasibility of robotic-assisted minimally invasive inguinal hernia repair in patients with urologic considerations including artificial urinary sphincters and bladder herniation.

Robotic surgical technology has the potential to broaden the applicability of minimally invasive approaches into more complex, technically challenging inguinal hernia repairs. A unique patient population requiring inguinal hernia repair are those patients who either have artificial urinary sphincters (AUS) or inguinal bladder herniation (IBH). Traditionally, these patients have not been considered candidates for minimally invasive inguinal hernia repairs. Through this retrospective series, we aim to contribute to the growing body of literature on robotic-assisted inguinal hernia repair (RIHR) by describing our experience with RIHR in this patient subset. We performed a retrospective chart review of RIHR cases performed from June 2017 to April 2019 by a single surgeon at our university-affiliated community hospital. Charts were reviewed for preoperative considerations, operative complications, and postoperative outcomes. A total of three patients with an AUS and six patients with IBH were included, all of whom were male. All the patients received transabdominal preperitoneal (TAPP) approaches, and all received placement of mesh. There were no intraoperative complications and no conversions to open surgery. Postoperatively, one patient with IBH had persistent surgical site pain that resolved after 3weeks and one patient, also with IBH, had a surgical site seroma that resolved without further intervention. Mean follow-up time was 10.71 and 12.13months for patients with AUS and IBH, respectively. No patients reported hernia recurrence during this time. This review suggests that the use of robotic assistance for laparoscopic inguinal hernia repair is safe and effective and may provide additional benefits for patients with concurrent urological considerations such as AUS and IBH.

Evaluating outcomes for robotic-assisted inguinal hernia repair in males with prior urologic surgery: a propensity-matched analysis from a national database.

Controversy exists regarding the safety and effectiveness of minimally invasive inguinal hernia repairs in patients with a history of prior urologic pelvic operations (PUPO), such as a prostatectomy, which causes scarring and disruption of the retropubic tissue planes. Our study sought to examine whether a history of PUPO impacts surgical outcomes in males undergoing robotic-assisted inguinal hernia repair. The Americas Hernia Society Quality Collaborative (AHSQC) database was queried to identify male patients who underwent a robotic inguinal hernia repair with 30-day follow-up. A sub-query was performed to identify subjects within the cohort with a documented history of PUPO. Propensity score matching was subsequently utilized to evaluate for differences in intra-operative complications and short-term post-operative outcomes. In total, 1664 male patients underwent robotic-assisted inguinal hernia repair, of whom 65 (3.9%) had a PUPO. After a 3:1 propensity score matching with hernia repair patients who did not have prior procedures, 195 (11.7%) males were included in the comparison cohort. There were no documented vascular, bladder, or spermatic cord injuries in either group. There was no difference in 30-day readmission rate (5% vs. 3%, respectively, p = 0.41). No hernia recurrences were recorded within the 30-day follow-up period in either group. There was no statistical difference in post-operative complications (including seroma formation, hematoma, and surgical site occurrences) between the two groups (14% vs. 8%, p = 0.18). In an experienced surgeon's hands, robotic-assisted minimally invasive inguinal hernia repair may be an alternative to open repair in patients with PUPO who were previously thought to be poor minimally invasive surgical candidates.

Prospective, multicenter, pairwise analysis of robotic-assisted inguinal hernia repair with open and laparoscopic inguinal hernia repair: early results from the Prospective Hernia Study.

To evaluate and compare peri-operative outcomes through 30days, including pain and quality of life (QOL) through 3months across three cohorts of inguinal hernia repair (IHR) patients (robotic-assisted, laparoscopic, and open IHR). The Prospective Hernia Study is an ongoing, multicenter, comparative, open-label analysis of clinical and patient-reported outcomes from robotic-assisted surgery (RAS) versus open and RAS versus laparoscopic IHR procedures. Patient responses to the Carolinas Comfort Scale (CCS) questionnaire provided QOL outcomes. 504 enrolled patients underwent unilateral or bilateral IHR (RAS, n = 159; open, n = 190; laparoscopic, n = 155) at 17 medical institutions from May 2016 through December 2018. Propensity score matching provided a balanced comparison: RAS versus open (n = 112 each) and RAS versus laparoscopic (n = 80 each). Overall, operative times were significantly different between the RAS and laparoscopic cases (83 vs. 65min; p < 0.001). Fewer RAS patients required prescription pain medication than either open (49.5% vs. 80.0%; p < 0.001) or laparoscopic patients (45.3% vs. 65.4%; p = 0.013). Median number of prescription pain pills taken differed for RAS vs. open (0.5 vs. 15.5; p = 0.001) and were comparable for RAS vs laparoscopic (7.0 vs. 6.0; p = 0.482) among patients taking prescribed pain medication. Time to return to normal activities differed for RAS vs. open (3 vs. 4days; p = 0.005) and were comparable for RAS vs. laparoscopic (4 vs. 4days; p = 0.657). Median CCS scores through 3months were comparable for the three approaches. Postoperative complication rates for the three groups also were comparable. One laparoscopic case was converted to open. This study demonstrates that IHR can be performed effectively with the robotic-assisted, laparoscopic, or open approaches. There was no difference in the median number of prescription pain medication pills taken between the RAS and laparoscopic groups. A difference was observed in the overall number of patients reporting the need to take prescription pain medication. Comparable operative times were observed for RAS unilateral IHR patients compared to open unilateral IHR patients; however, operative times for RAS overall and bilateral subjects were longer than for open patients. Operative times were longer overall for RAS patients compared to laparoscopic patients; however, there was no difference in conversion and complication rate in the RAS vs. laparoscopic groups or the complication rate in the RAS vs. open group. Time to return to normal activities for RAS IHR patients was comparable to that of laparoscopically repaired patients and significantly sooner compared to open IHR patients.

Robotic inguinal hernia repair: Is it a new era in the management of inguinal hernia?

ObjectiveWe compared outcomes of elective inguinal hernia repair performed at one institution by three approaches: robotic-assistance, laparoscopic, and open. MethodsCharacteristics of the patients, the hernia and the procedures performed during 2014–2016 were accessed from patient electronic medical files of 137 elective inguinal hernia repairs. 24 surgeries were robotic-assisted, 16 laparoscopic and 97 open repairs. ResultsDistributions of age, sex and BMI did not differ between the groups. Bilateral repair was more common in the robotic (70.8%) than the laparoscopic (50.0%) and open groups (12.4%) (p < 0.001). Direct hernias were more common in the open (45.4%) than the robotic (20.8%) and laparoscopic (12.5%) groups (p < 0.001). Only 3 hernias were inguinoscrotal, all in the robotic group. The median operation times were 44.0, 79.0 and 92.5 min for the open, laparoscopic and robotic methods, respectively (p < 0.001). Among the unilateral repairs, the median operative times were the same for the robotic and laparoscopic procedures, 73 min, and less for the open procedures, 40 min. The proportion of patients hospitalized for 2–3 days was higher for open repair (13.4% vs. 6.2% and 0% for laparoscopic and robotic), but this difference was not statistically significant. The median maximal postoperative pain according to a 0-10-point visual analogue score was 5.0, 2.0 and 0 for open, laparoscopic and robotic procedures, respectively (p < 0.001). ConclusionsThis report demonstrated the safety and feasibility of robotic-assisted inguinal hernia repair.

Robotic-assisted versus laparoscopic unilateral inguinal hernia repair: a comprehensive cost analysis.

Cost-effectiveness of robotic-assisted surgery is still debatable. Robotic-assisted inguinal hernia repair has no clear clinical benefit over laparoscopic repair. We performed a comprehensive cost-analysis comparison between the two approaches for evaluation of their cost-effectiveness in a large healthcare system in the Western United States. Health records in 32 hospitals were queried for procedural costs of inguinal hernia repairs between January 2015 and March 2017. Elective robotic-assisted or laparoscopic unilateral inguinal hernia repairs were included. Cost calculations were done using a utilization-based costing model. Total cost included: fixed cost, which comprises medical device and personnel costs, and variable cost, which comprises disposables and reusable instruments costs. Other outcome measures were length of stay (LOS), conversion to open, and operative times. Statistics were done using t test for continuous variables and χ2 test for categorical variables. A p-value < 0.05 was considered significant. A total of 2405 cases, 734 robotic-assisted (633 Primary: 101 recurrent) and 1671 laparoscopic (1471 Primary: 200 recurrent), were included. The average total cost was significantly higher (p < 0.001) in the robotic-assisted group ($5517) compared to the laparoscopic group ($3269). However, the average laparoscopic variable cost ($1105) was significantly higher (p < 0.001) than the robotic-assisted cost ($933). Whereas there was no significant difference between the two groups for LOS and conversion to open, average operative times were significantly higher in the robotic-assisted group (p < 0.001). Subgroup analysis for primary and recurrent inguinal hernias matched the overall results. Robotic-assisted inguinal hernia repair has a significantly higher cost and significantly longer operative times, compared to the laparoscopic approach. The study has shown that only fixed cost contributes to the cost difference between the two approaches. Medical device cost plus the longer operative times are the main factors driving the cost difference. Laparoscopic unilateral inguinal hernia repair is more cost-effective compared to a robotic-assisted approach.

Patient perceptions of acute pain and activity disruption following inguinal hernia repair: a propensity-matched comparison of robotic-assisted, laparoscopic, and open approaches

Few publications describe the potential benefit of robotic-assisted inguinal hernia repair on acute postoperative groin pain (APGP). This study compared patients’ perceptions of APGP, activity limitation, and overall satisfaction after robotic-assisted- (R), laparoscopic (L), or open (O) inguinal hernia repair (IHR). Random samples of patients from two web-based research panels and surgical practices were screened for patients who underwent IHR between October 28, 2015 and November 1, 2016. Qualified patients were surveyed to assess perceived APGP at 1 week postoperatively, activity disruption, and overall satisfaction. Three cohorts based on operative approach were compared after propensity matching. Propensity scoring resulted in 83 R-IHR matched to 83 L-IHR respondents, while 85 R-IHR matched with 85 O-IHR respondents. R-IHR respondents recalled less APGP compared to respondents who had O-IHR (4.1 ± 0.3 vs 5.6 ± 0.3, p < 0.01) but similar APGP compared to L-IHR (4.0 ± 0.3 vs 4.4 ± 0.3, p = 0.37). Respondents recalled less activity disruption 1 week postoperatively after R-IHR versus O-IHR (6.1 ± 0.3 vs. 7.3 ± 0.2, p < 0.01) but similar levels of activity disruption after R-IHR and L-IHR (6.0 ± 0.3 vs. 6.6 ± 0.27, p = 0.32). At the time of the survey, respondents perceived less physical activity disruption after R-IHR compared to O-IHR (1.4 ± 0.2 vs. 2.8 ± 0.4, p < 0.01) but similar between R-IHR and L-IHR (1.3 ± 0.2 vs 1.2 ± 0.2, p = 0.94). Most respondents felt satisfied with their outcome regardless of operative approach. Patient perceptions of pain and activity disruption differ by approach, suggesting a potential advantage of a minimally invasive technique over open for IHR. Further studies are warranted to determine long-term outcomes regarding pain and quality of life after IHR.