Edelman David S
Surg Technol Int. 2020 May 28;36:99-104.
Laparoscopic inguinal hernia repair has certain advantages over open repair including less pain and earlier return to normal activity. Robotic surgery adds high definition visualization and articulating instruments. This enhanced dexterity can make laparoscopic hernia repair more refined while obtaining a critical view of the myopectineal orifice that should lead to fewer recurrences and complications. A series of robotic, laparoscopic, inguinal hernia repairs by a single surgeon with extensive laparoscopic hernia experience at a single institution along with a review of the literature was undertaken to determine the role of robotic laparoscopic inguinal hernia repair in minimally invasive surgery.
One thousand laparoscopic inguinal hernia operations were performed from April 2012 through March 2020. There were 420 cases of robotic trans-abdominal pre-peritoneal (TAPP) procedures done during that time. Hospital records and follow-up care were prospectively reviewed and data was collected for age, sex, American Society of Anesthesia (ASA) class, and operative time. Follow up was done at two weeks, eight weeks, and 16 weeks following surgery. All patients consented for study.
Ninety-four percent (94%) of the patients were male. Age averaged 57.8 years with a range of 18-85 years. ASA averaged 2.01 with comorbidities of hypertension, hypercholesterolemia, and GERD being the most common. Body mass index (BMI) was between 19-40.5 averaging 26.6. Sixty-three patients (15%) had an umbilical hernia repair done concomitantly. Operating room (OR) time ranged from 25-140 minutes, with an average of 54.36 minutes, and decreased as experience increased. One patient with a large, left scrotal hernia was converted to open, one patient developed perforated sigmoid diverticulitis seven days postoperative and four recurred indirectly after a direct hernia repair. Urinary retention was the most problematic postoperative occurrence.
Robotic inguinal hernia repair is safe and effective. 1) Proper training, including simulators and proctors, is necessary; 2) having the same operating room team and an interested first assistant at the OR table is very helpful; 3) the learning curve is about 50 patients; 4) postoperative narcotics are rarely more than three hydrocodone pills; 4) no fixation of the mesh is necessary, but fibrin sealant was used routinely in these patients; and 5) urinary retention is the most common postoperative issue and is best planned for by knowing the patients urinary history, use of peripheral alpha-blockers, and straight catheterization in the OR at the conclusion of the surgery. OR time was longer than standard laparoscopic herniorrhaphy but decreased with experience. The robotic technique allowed for an excellent view of the myopectineal orifice and appears to have a low complication rate.
腹腔镜腹股沟疝修补术相较于开放手术具有某些优势，包括疼痛减轻和更早恢复正常活动。机器人手术增加了高清视野和可弯曲器械。这种增强的灵活性可使腹腔镜疝修补术更加精细，同时获得耻骨肌孔的关键视野，这应能减少复发和并发症。我们进行了一系列由一位在单一机构拥有丰富腹腔镜疝手术经验的外科医生实施的机器人辅助腹腔镜腹股沟疝修补术，并对文献进行了回顾，以确定机器人辅助腹腔镜腹股沟疝修补术在微创手术中的作用。
2012年4月至2020年3月期间共进行了1000例腹腔镜腹股沟疝手术。在此期间，有420例机器人经腹腹膜前（TAPP）手术。对医院记录和随访护理进行了前瞻性回顾，并收集了年龄、性别、美国麻醉医师协会（ASA）分级和手术时间等数据。术后两周、八周和十六周进行随访。所有患者均同意参与研究。
94%的患者为男性。平均年龄57.8岁，范围为18 - 85岁。ASA平均分级为2.01，最常见的合并症为高血压、高胆固醇血症和胃食管反流病。体重指数（BMI）在19 - 40.5之间，平均为26.6。63例患者（15%）同时进行了脐疝修补术。手术室（OR）时间为25 - 140分钟，平均为54.36分钟，且随着经验增加而减少。1例巨大左侧阴囊疝患者转为开放手术，1例患者术后7天发生乙状结肠憩室穿孔，4例在直接疝修补术后间接复发。尿潴留是最棘手的术后情况。
机器人腹股沟疝修补术安全有效。1）适当的培训，包括模拟器和指导者，是必要的；2）拥有相同的手术室团队和手术台上感兴趣的第一助手非常有帮助；3）学习曲线约为50例患者；4）术后使用的麻醉药很少超过三片氢可酮；4）无需固定补片，但这些患者常规使用纤维蛋白密封剂；5）尿潴留是最常见的术后问题，最好通过了解患者的排尿史、使用外周α受体阻滞剂以及在手术结束时在手术室进行直接导尿来做好应对准备。手术室时间比标准腹腔镜疝修补术长，但随着经验增加而减少。机器人技术可提供耻骨肌孔的极佳视野，且并发症发生率似乎较低。
